Ontario Health Plan for an Influenza Pandemic
We are pleased to release the fifth edition of the Ontario Health Plan for an Influenza Pandemic (OHPIP), which is designed to guide planning for an influenza pandemic at both the provincial and local levels across Ontario. After five years of pandemic planning, Ontario has made significant progress. We have in place a stockpile of antivirals large enough to meet the needs of people who will be sick enough to require treatment. Our stockpiles of other supplies and materials are almost complete. We have also developed the relationships, communications mechanisms and expertise across the health care system that will allow us to act quickly and consistently to protect the public and reduce the impact of an influenza pandemic, when an emergency of this magnitude occurs. The 2008 edition of OHPIP provides more detail on the following aspects of pandemic planning: surveillance and reporting systems to monitor a pandemic; occupational health and safety and infection prevention and control measures; the timing, use and availability of antiviral treatment; and the organization and delivery of influenza-related primary care services, including assessment, treatment and referral services. The 2008 edition also includes revisions to the planning guidelines for laboratories, paediatric services and long-term care homes. In addition, OHPIP 2008 provides new chapters on planning and managing certain essential health services during a pandemic, including the services required by people with chronic kidney disease or acute kidney injury, and the province’s blood services. Ontario is committed to keeping OHPIP up to date, to keeping our plan aligned with the planning assumptions of the Canadian Pandemic Influenza Plan (CPIP), and to revising OHPIP as required to reflect new knowledge and information. We are also committed to the “precautionary principle” set out by Justice Campbell in the final report of the SARS Commission (December 2006), which requires us to take reasonable steps in the face of scientific uncertainty to reduce risk in areas of critical importance such as the protection of health care workers in the workplace. Once again, Ontario is deeply indebted to the hundreds of individuals and organizations who have served on OHPIP committees and working groups, and contributed to developing our plan, to enhancing our preparedness, and to protecting the health and well-being of their fellow Ontarians. In particular, we would like to mark the fifth anniversary of pandemic planning in Ontario by dedicating the OHPIP to Dr. Sheela Basrur, the former Chief Medical Officer of Health for Ontario, whose leadership and commitment to public health were the driving forces behind pandemic planning in Ontario.
The Honourable David Caplan Minister
Dr. David Williams Chief Medical Officer of Health (Acting)
Ontario Health Plan for an Influenza Pandemic August 2008
Table of Contents Preface Part I: The Context for Planning for an Influenza Pandemic Chapter 1
Background
Chapter 2
Roles, Responsibilities and Frameworks for Decision-Making
Chapter 3
Planning Goals, Approach and Assumptions
Chapter 4
Resources
Part II: System-Wide Issues, Activities and Tools Chapter 5
Surveillance -- Detecting and Monitoring the Spread of Influenza
Chapter 6
Public Health Measures -- Managing the Spread of Influenza
Chapter 7
Infection Prevention and Control and Occupational Health and Safety
Chapter 8
Optimizing Deployment of the Health Workforce
Chapter 9
Antivirals and Vaccine
Chapter 10
Equipment and Supplies
Chapter 11
Influenza Assessment, Treatment and Referral Centres
Chapter 12
Communications
Part III: Setting-Specific Issues, Activities and Tools Chapter 13
Public Health Services
Chapter 14
Laboratory Services
Chapter 15
Emergency Health Services
Chapter 16
Community Health Services
Chapter 17
Acute Care Services 17B Cancer Care Ontario Pandemic Planning Clinical Guideline 17C Clinical Care of Patients with Chronic Kidney Disease/Acute Kidney Injury During an Influenza Pandemic 17D Ontairo Contingency Plan for Management of Blood Shortages
Chapter 18
Paediatric Services
Chapter 19
Long-Term Care
Chapter 20
Guidelines for First Nations Communities
Chapter 21
Psychosocial Support for Health Care Workers and the Public
Chapter 22
Natural Death Surge Planning
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Ontario Health Plan for an Influenza Pandemic August 2008
Cette publication hautement spécialisée n'est disponible qu'en anglais en vertu du règlement 441/97, qui en exempte l'application de la Loi sur les services en français. Pour obtenir de l'aide en français, veuillez communiquer avec le ministère de la Santé et des Soins de longue durée au (416) 327-8974.
Where this document refers to specific legal requirements, this information is being provided for information purposes to assist the parties in complying with these requirements and does not represent legal advice. The parties should refer to the specific requirements in the relevant legislation and seek the advice of counsel if they have any questions.
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Ontario Health Plan for an Influenza Pandemic August 2008
Preface About the Ontario Health Plan for an Influenza Pandemic This is the fourth edition of the Ontario Health Plan for an Influenza Pandemic (OHPIP), which is designed to guide planning at both the provincial and local levels across Ontario. It describes how Ontario’s health care system will respond to an influenza pandemic. OHPIP sets out a comprehensive province-wide approach to health preparedness and response planning, and provides information to guide local pandemic planning groups. OHPIP endeavours to strike a balance between providing enough direction to ensure a consistent provincial health response to an influenza pandemic, and giving local jurisdictions the flexibility to respond to different scenarios that may arise during a pandemic. The process of developing OHPIP is managed and coordinated by the Emergency Management Unit (EMU) of the Ministry of Health and Long-Term Care. In the event of an influenza pandemic, the health care system’s response will be managed out of a Ministry Emergency Operations Centre (MEOC) located in the EMU. OHPIP is a living document. It is reviewed annually (or more often if required) and revised to reflect current knowledge and best practices. The steering committee established to oversee health planning for an influenza pandemic includes representatives from emergency management, public health, laboratories, the health care delivery system, labour associations, and regulatory colleges. While OHPIP focuses on pandemic planning for the health sector, it includes Preface
links to other ministries with emergency responsibilities such as Emergency Management Ontario (EMO) of the Ministry of Community Safety and Correctional Services, the Ministry of Community and Social Services, the Ministry of Children and Youth Services, and the Ministry of Labour. Because a pandemic will affect every sector of society, EMO has worked with other provincial ministries and their stakeholders to develop a Provincial Coordinating Plan for an Influenza Pandemic, available on the EMU website: www.health.gov.on.ca/pandemic. That plan will address pandemic planning issues outside the health sector, and focus on maintaining critical infrastructure and meeting human needs.
Occupational Health and Safety Health care facilities are required to comply with applicable provisions of the Occupational Health and Safety Act (OHSA) and its regulations. Employers, supervisors and workers have rights, duties and obligations under the OHSA. To see the specific requirements under the OHSA, go to: http://www.e-laws.gov.on.ca/html/ statutes/english/elaws_statutes_ 90o01_e.htm The Occupational Health and Safety Act places duties on many different categories of individuals associated with workplaces, such as employers, constructors, supervisors, owners, suppliers, licensees, officers of a corporation and workers. A guide to the requirements of the iii
Ontario Health Plan for an Influenza Pandemic August 2008
Occupational Health and Safety Act may be found at: http://www.labour.gov.on.ca/english/ hs/ohsaguide/index.html In addition, the OHSA section 25(2)(h) requires an employer to take every precaution reasonable in the circumstances for the protection of a worker. Specific requirements for certain health care and residential facilities may be found in the Regulation for Health Care and Residential Facilities. Go to: http://www.e-laws.gov.on.ca/html/ regs/english/elaws_regs_930067_e.htm There is a general duty for an employer to establish written measures and procedures for the health and safety of workers, in consultation with the joint health and safety committee or health and safety representative, if any. Such measures and procedures may include, but are not limited to, the following:
employer or by the Regulation for Health Care and Residential Facilities to wear or use any protective clothing, equipment or device shall be instructed and trained in its care, use and limitations before wearing or using it for the first time and at regular intervals thereafter and the worker shall participate in such instruction and training. The employer is reminded of the need to be able to demonstrate training, and is therefore encouraged to document the workers trained, the dates training was conducted, and materials covered during training. Under the Occupational Health and Safety Act, a worker must work in compliance with the Act and its regulations, and use or wear any equipment, protective devices or clothing required by the employer. For more information, please contact your local Ministry of Labour office. A list of local Ministry of Labour offices in Ontario may be found at http://www.labour.gov.on.ca/
safe work practices
How to Use This Document
safe working conditions
OHPIP is organized into three sections and 22 chapters. The sections are:
proper hygiene practices and the use of hygiene facilities
I.
The Context for Planning for an Influenza Pandemic
II.
System-Wide Issues, Activities and Tools
III.
Setting-Specific Issues, Activities and Tools
the control of infections. At least once a year the measures and procedures for the health and safety of workers shall be reviewed and revised in the light of current knowledge and practice. The employer, in consultation with the joint health and safety committee or health and safety representative, if any, shall develop, establish and provide training and educational programs in health and safety measures and procedures for workers that are relevant to the workers’ work. A worker who is required by his or her
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Individuals responsible for overall pandemic planning will benefit from reading the entire plan. Individuals responsible for planning for one particular part of the health response (e.g., primary care services, long-term care homes) will also benefit from reading the entire plan, but they may choose just to read those sections and chapters that are relevant to
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their work.
4.
For example:
UPDATED – Resources: provides a list of resources for pandemic planning.
• Primary care planners will be most interested in Section I, Section II, and Chapter 11 of Section III.
• People responsible for pandemic planning in long-term care homes will be most interested in Section I, Section II and Chapter 19 of Section III.
Chapter Overviews The following chapter overviews describe the type of information in each chapter, and whether the chapter has been updated (additions, minor changes) or revised (substantially changed) in 2008. I The Context for Planning for an Influenza Pandemic 1. Background: provides basic information about influenza and pandemics. 2.
3.
UPDATED – Roles, Responsibilities and Frameworks for Decision Making: describes the phases of an influenza pandemic, the roles and responsibilities of different levels of government, and the ethical and emergency management frameworks that provide the basis for Ontario’s plan and response. In the 2008 edition, this chapter has been updated to include any changes in provincial emergency management and health legislation as well as the federal emergency legislation. Planning Goals, Approach and Assumptions: sets out the goals, strategic approach and planning assumptions for Ontario’s plan.
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II System-Wide Issues, Activities and Tools 5. UPDATED Surveillance – Detecting and Monitoring the Spread of Influenza: describes the surveillance activities in place now to monitor influenza in Ontario and detect a pandemic virus strain, as well as those that will be added or changed during a pandemic. The 2008 edition includes some changes to proposed surveillance for an influenza pandemic and provides some information on the web-based surveillance system that will be used for reporting during a pandemic. It also describes how surveillance information will be communicated to the field. 6.
Public Health Measures – Managing the Spread of Influenza: describes the public health measures that Ontario will use during a pandemic, the triggers for implementing those measures, and the factors that will determine the type and duration of public health measures.
7.
REVISED – Occupational Health and Safety and Infection Prevention and Control: reinforces the responsibility of employers to provide safe working conditions, and sets out the range of steps that health care organizations, health care workers and the public can take to prevent the spread of influenza and to protect the health workforce. The chapter applies a hierarchy of controls approach to occupational health and safety during a
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pandemic, and identifies a range of strategies to reduce risk, including risk, assessments, education and training, modifications to the physical environment, changes to administrative and work practices, and appropriate use of personal protective equipment and other infection control measures. 8.
Optimizing Deployment of the Health Workforce: describes a competency-based approach to health human resources planning for a pandemic, and the steps that planners, employers and health care workers can take to make the most effective use of knowledge and skills during a pandemic.
9.
UPDATED – Antivirals and Vaccines: sets out the policies for antiviral and vaccine supply, distribution and use, and describes the steps Ontario has taken to develop an antiviral stockpile as well as plans to acquire and distribute antivirals and vaccine during a pandemic. It also provides important information on the timing of antiviral treatment, antiviral stockpiles, and how antivirals will be distributed.
10.
11.
Equipment and Supplies: describes the steps that Ontario and health care organizations will take to ensure an adequate, secure supply of equipment and supplies during a pandemic. REVISED – Influenza Assessment, Treatment and Referral: describes the approach that Ontario will take to provide influenza-related primary care services during a pandemic (i.e., influenza assessment, treatment and referral services). It describes how
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Ontario will use existing primary care services – including Telehealth, family health teams, physicians (including paediatricians), other primary care practitioners, community health centres, walk-in clinics and pharmacies – to provide influenza assessment, treatment and referral services. It also describes how communities will plan for alternatives, such as dedicated Flu Centres, in the event existing primary care services are overwhelmed due to the severity of the pandemic. The 2008 edition of OHPIP describes strategies that primary care services can use to meet the need for influenza-related services as well as the steps required to establish and staff Flu Centres. 12.
Communications: describes the steps that the Ministry of Health and Long-Term Care (MOHLTC) will use to communicate with the public, health care workers and other stakeholders during an influenza pandemic, and provides tools that health care organizations can use to plan their communications activities.
III Setting-Specific Issues, Activities and Tools 13. Public Health Services: sets out the steps the public health system will take to manage the demand for services during an influenza pandemic. 14.
UPDATED – Laboratory Services: describes how the laboratory system will function during a pandemic, including tests that will be provided and those that may be curtailed or reduced.
15.
Emergency Health Services: describes the steps that Emergency vi
Ontario Health Plan for an Influenza Pandemic August 2008
Medical Services will take to maintain land and air ambulance services during a pandemic. 16.
Community Health Services: includes a plan to maintain community-based mental health and addiction services during a pandemic.
17.
UPDATED – Acute Care Services: sets out approaches that acute care hospitals can use to manage their resources during a pandemic, including determining who will be admitted to critical care and how acute care settings will make decisions about limited resources. The 2008 edition of OHPIP puts information on managing and maintaining essential health services for a particular disease or population group in separate sections, which include: cancer services (developed in 2007), chronic kidney disease and acute kidney injury (new in 2008) and blood services (new in 2008).
18.
19.
UPDATED – Paediatric Services: discusses the services required to provide care for children and pregnant women during a pandemic and provides new decision support tools for parents/caregivers and health care providers. The chapter has been updated to include more information and tools. REVISED – Long-Term Care Homes: sets out guidelines for longterm care homes designed to protect residents and staff during a
Preface
pandemic, and help long-term care homes continue to provide high quality care. 20.
First Nations: describes the collaborative efforts of the Province of Ontario, the Government of Canada (through First Nations and Inuit Health), and the First Nations communities to meet the needs of First Nations communities during a pandemic.
21.
NEW – Psychosocial Support: provides the outline for a chapter on psychosocial support during an influenza pandemic for health care workers, patients and the public that is currently under development.
22.
NEW – Natural Death Surge Planning: outlines the steps in the death management process including the proper screening, recognition, reporting of and disposition of human remains at the local level.
The diagram in Figure 1 is a summary of the activities described in detail in the OHPIP by each of the WHO Pandemic Periods. If you have any questions about the 2008 edition of OHPIP, or related pandemic planning initiatives, please contact the ministry’s Emergency Management Unit through the Healthcare Provider Hotline at 1-866-212-2272 (available MondayFriday from 8:30am – 5:00pm) or by email:
[email protected].
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 1: Summary of Pandemic Planning and Response Activities by Pandemic Period
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Ontario Health Plan for an Influenza Pandemic August 2008
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Ontario Health Plan for an Influenza Pandemic August 2008
List of Abbreviations Abbreviation
Name
CIDPC
Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada
CCMOH
Council of Chief Medical Officers of Health, Public Health Agency of Canada
CIOSC
Canadian Integrated Outbreak Surveillance Centre, Public Health Agency of Canada
CMOH
Chief Medical Officer of Health, Ontario
CNPHI
Canadian Network for Public Health Intelligence, Public Health Agency of Canada
CPHLN
Canadian Public Health Laboratory Network, Public Health Agency of Canada
CPIP
Canadian Pandemic Influenza Plan, Public Health Agency of Canada
EMO
Emergency Management Ontario
EMU
Emergency Management Unit, Ontario Ministry of Health and Long-Term Care
EOC
Emergency Operations Centre, Ontario Ministry of Health and Long-Term Care
F/P/T
Federal/Provincial/ Territorial
HHR
Health Human Resources
iPHIS
integrated Public Health Information System, Ontario Ministry of Health and Long-Term Care
HU
Health Unit
MOH
Medical Officer of Health
MOHLTC
Ontario Ministry of Health and Long-Term Care
MCSCS
Ontario Ministry of Community Safety and Correctional Services
MCSS
Ontario Ministry of Community and Social Services
MOL
Ontario Ministry of Labour
NACI
National Advisory Committee on Immunization, Public Health Agency of Canada
NML
National Microbiology Laboratory, Public Health Agency of Canada
OHPIP
Ontario Health Plan for an Influenza Pandemic, Ontario Ministry of Health and Long-Term Care
PAHO
Pan American Health Organization
PEOC
Provincial Emergency Operations Centre
PHAC
Public Health Agency of Canada
PHD
Public Health Division, Ontario Ministry of Health and Long-Term Care
PIC
Pandemic Influenza Committee, Public Health Agency of Canada
PIDAC
Provincial Infectious Diseases Advisory Committee, Ontario Ministry of Health and Long-Term Care
PPE
Personal Protective Equipment
P/T
Provincial/Territorial
PTAC
Provincial Transfer Authorization Centre, Ontario Ministry of Health and Long-Term Care
RCMP
Royal Canadian Mounted Police
UIIP
Universal Influenza Immunization Program, Ontario Ministry of Health and Long-Term Care
VAAE
Vaccine Associated Adverse Events
VAER
Vaccine Adverse Events Reporting
WHO
World Health Organization
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Ontario Health Plan for an Influenza Pandemic August 2008
Acknowledgments Over 400 individuals from public health, clinical care, labour, professional associations, regulatory colleges and government provided their time and expertise to help develop the Ontario Health Plan for an Influenza Pandemic, past and present. The Ministry of Health and Long-Term Care acknowledges their hard work and dedication to protecting the health and safety of Ontarians. The Ministry would also like to acknowledge the support of their employers and colleagues in enabling them to participate in this process. Rogelio Abarca
St. Michael’s Hospital
Yoel Abells
Ontario College of Family Physicians
Tom Abercrombie
Ontario Ministry of Labour
Mary Addison
Management Board of Cabinet – Ontario Shared Services – Supply Chain Management
Jill Adolphe
The Hospital for Sick Children
Rob Alder
Consultant
Douglas Alderson
Consultant
Carole Alexander
Ministry of Health and Long-Term Care – Community Health Division
Amira Ali
Ottawa Public Health
Ken Allan
Thunder Bay District Health Unit
Ann Frances Allen
College of Nurses of Ontario
Janet Allen
Regional Infection Control Networks
Malle Allen
Ministry of Health and Long-Term Care – Communications & Information Branch
Upton Allen
Hospital for Sick Children
Esther Allen-Fogarty
Nurse Practitioners’ Association of Ontario
Linda An
Ministry of Health and Long-Term Care – Health Professions Regulatory Policy & Programs Branch
Krishnapriya Anchala
McMaster Children’s Hospital
Joanne Anderson
York Region Health Services Department
Beverley J. Antle
Ontario Association for Social Workers
Tracy Antone
Chiefs of Ontario
Irene Armstrong
Association of Local Public Health Agencies
Jim Armstrong
Ontario Association of Community Care Access Centres
Nancy Armstrong
Ministry of Health and Long-Term Care – Communications & Information Branch
Richard Armstrong
Durham Region Emergency Medical Services
Paula Arnold
Ottawa Public Health
Judy Ash
Ontario Association of Medical Laboratories
Madeleine Ashcroft
Regional Infection Control Networks
Gordon Aue
Ministry of Health and Long-Term Care- Operational Support Branch
Kim Auld
Toronto Public Health
Debbie Babbington
Mental Health and Addictions Branch
Jean Bacon
Writer
Nancy Bagworth
Canadian Association of Chain Drug Stores
Naideen Bailey
Region of Waterloo Public Health
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Ontario Health Plan for an Influenza Pandemic August 2008
Irmajean Bajnok
Registered Nurses Association of Ontario
Kim Barker
Assembly of First Nations
Tara Baron
Northern Ontario School of Medicine
Michael Barrett
St. Joseph’s Health Care London
Hafeeza Bassirullah
Ministry of Health and Long-Term Care – Emergency Management Unit
Maysie Bautista
Ministry of Health and Long-Term Care – Emergency Management Unit
Sandra Baxter
Ministry of Health and Long-Term Care – Human Services I&IT Cluster
Mary Bayliss
College of Respiratory Therapists
Kathryn Beaton
Ministry of Health and Long-Term Care – Human Services I&IT Cluster
Gail Beatty
Registered Nurses’ Association of Ontario
Andre Luc Beauregard
Peel Public Health
Tom Bedford
Association of Municipal Medical Emergency Services of Ontario
Barbara Belanger
Ontario Long-Term Care Association
Lisa Berger
Toronto Public Health
Raj Bhanot
Ontario Hospital Association
Darlene Binette
Thunder Bay District Health Unit
Valerie Bishop-de-Young
Ontario Community Support Association
Ari Bitnun
Hospital for Sick Children
Dr. Mohan Biyani
The Ottawa Hospital
Deanna Blair
Ministry of Health and Long-Term Care – Communications & Information Branch
Ted Boadway
Ontario Medical Association
Stephanie Bolton
Independent Diagnostics Clinics Association
Erika Bontovics
Ministry of Health and Long-Term Care – Infectious Disease Branch
Marilyn Booth
Ontario Children’s Health Network
Patti Boucher
Ontario Safety Association for Community & Healthcare
Anne Bowlby
Mental Health and Addictions Branch
Gary Bragagnolo
Ministry of Health and Long-Term Care- Emergency Health Services Branch
Mark Breen
Ministry of Health and Long-Term Care – Emergency Management Unit
Helen Brenner
Lakeridge Health Corporation
Michelle Brosseau
Ontario Nurses’ Association
Dennis Brown
Ontario Ministry of Health and Long-Term Care, Emergency Health Services Branch
Cindy Bruce-Barrett
The Hospital for Sick Children
Sandy Buchman
Ontario College of Family Physicians
Jenny Buckley
Consultant
Mark Burgess
Quinte Healthcare Corporation
Frederick Burkle
Bloomberg School of Public Health, John Hopkins University
Vanessa Burkowski
Windsor Regional Hospital
Laura Burton
Ministry of Health and Long-Term Care – Laboratories Branch
Terri Burton
Association of Municipal Medical Emergency Services of Ontario
Doreen Cachagee
First Nations and Inuit Health, Ontario Region
Patricia Caldwell
Ontario Nurses’ Association
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Ontario Health Plan for an Influenza Pandemic August 2008
Sandra Callery
Sunnybrook Health Sciences Centre
Johanne Carboneau
Clinidata Services Corporation
Anne Carter
Leeds, Grenville & Lanark District Health Unit
Debra Carew
Sunnybrook Health Sciences Centre
Bill Casey
Peterborough Family Health Team
Rheney Castillo
Mount Sinai Hospital
Umberto Cellupica
Ontario Medical Association
Eng-Soon Chan
Ministry of Health and Long-Term Care – Infectious Disease Branch
Judy Chaperon
Hôpital régional de Sudbury Regional Hospital, CKD Regional Program
Liz Chappel
Ontario Multifaith Council
Monique Châteauvert
Ministry of Education
David Choat
The Scarborough Hospital
Michael Christian
McMaster University
Chris Churchill
Hospital for Sick Children
Maureen Cividino
Ontario College of Family Physicians
Melissa Clarke
Trillium Health Centre
Lorne Coe
Association of Municipalities of Ontario
Anne Coghlan
College of Nurses of Ontario
Allan Cole
MacKinnon & Bowes Ltd. (Funeral Services)
Kristin Comar
Hospital for Sick Children
Tim Cook
Mount Sinai Hospital
Nancy Cooper
Ontario Long-Term Care Association
Ann Corner
Simcoe Muskoka District Health Unit
Kevin Coughlin
London Health Sciences Centre
Molly Court
Markham Stouffville Hospital
Jean-Pierre Courteau
First Nations & Inuit Health, Ontario Region
Debby Cox
William Osler Health Centre
Tina Craig
Toronto Community Care Access Centre
Kay Cranston
Thunder Bay Regional Hospital
Mary Margaret Crapper
Ministry of Health and Long-Term Care – Communications & Information Branch
David Creery
Children’s Hospital of Eastern Ontario
Paula Cripps-McMartin
Allied Health University Health Network
Della Croteau
Ontario College of Pharmacists
Natasha Crowcroft
Ministry of Health and Long-Term Care
Robert Cullen
Hospital Logistics Inc. (Supply Chain Management Solutions)
Fiona Dalziel
Ministry of Labour
Audrey Danaher
Registered Nurses Association of Ontario
Nadia Daniell
Ontario Medical Association
Celia D'Aoust
The Ottawa Hospital
Brad Davey
Connex Ontario
Scott Davis
Elgin St. Thomas
Troy Day
Queen’s University
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Ontario Health Plan for an Influenza Pandemic August 2008
Mary Lou Decou
Regional Niagara Public Health Department
Sandra Del Signore
St. Michael’s Hospital
Steve Demacio
Ministry of Health and Long-Term Care- Health Services I & IT Cluster
Carrie Deverell
Ministry of Health and Long-Term Care – Communications & Information Branch
Natalie Diduch
Ministry of Health and Long-Term Care – Home Care & Support Branch
Lee Donohue
Ontario College of Family Physicians
Debbie Douglas
Ontario Council of Agencies Serving Immigrants
Carolyn Doxtator
Association of Iroquois & Allied Indians
Linda Dresser
Mount Sinai Hospital
Claudine D’Souza
Ministry of Health and Long-Term Care, Infectious Diseases Branch
Lynda Dukacz
Timmins & District Hospital
Michael Dunn
Sunnybrook Health Sciences Centre
Mary Dwyer
Ministry of Community Safety & Correctional Services
Bronwen Edgar
Ontario Public Health Association
Cathy Egan
Middlesex-London Health Unit
Michael Eliadis
The Hospital for Sick Children
Chris Elliot
Hospital for Sick Children
Karen Essery
Northwestern Health Unit
Vera Etches
Sudbury & District Health Unit
Gerald A. Evans
Queen's University – Kingston General Hospital
Morris Faccin
York Region Emergency Medical Services
Karen Faith
Sunnybrook Health Sciences Centre
Kelly Falzon
Credit Valley Hospital
Susy Faria
Ministry of Health and Long-Term Care- Emergency Management Unit
Laura Farrell
Huron County Health Unit
Irwin Fefergrad
Royal College of Dental Surgeons of Ontario
Paul Felstein
Consultant
David Fishman
Ministry of Health and Long-Term Care
Gordon Fleming
Association of Local Public Health Agencies
Dennis Fong
Ontario Association of Community Care Access Centres
Wendy Fortier
The Ottawa Hospital
Cara Francis
Ontario Hospital Association
Sarah Friesen
Shared Healthcare Supply Services
Brian Gamble
College of Physicians & Surgeons of Ontario
Greg Gamble
Thunder Bay Regional Health Sciences Centre
Linda Gallagher
Canadian Mental Health Association
Michael Gardam
University Health Network
Charles Gardner
Leeds, Grenville & Lanark District Health Unit
Derek Gascoigne
Thunder Bay Regional Health Sciences Centre
Rick Gaukel
Ministry of Health and Long-Term Care- Supply & Financial Services Branch
Ken Gazdic
Hopital Regional de Sudbury Regional Hospital
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Ontario Health Plan for an Influenza Pandemic August 2008
Ian Gemmill
Kingston, Frontenac and Lennox & Addington Health Unit
Leon Genesove
Ministry of Labour
Vikki German
Mental Health and Addictions Branch
Carrie Gerstein
College of Physicians & Surgeons of Ontario
Jennifer Gibson
Joint Centre for Bioethics- University of Toronto
Leah Gitterman
University Health Network
Paul Gould
Ontario Association of Medical Laboratories
Effie Gournis
Toronto Public Health
Doug Gowans
Ministry of Health and Long-Term Care- Community Health Division
Edwina Gracias
Peterborough County-City Public Health Unit
Kathy-L Graham
Association of Day Care Operators
Linda Graham
Canadian Mental Health Association
Phil Graham
Ministry of Health and Long-Term Care – Emergency Management Unit
Gilles Grenier
The Ottawa Hospital
Sandra Grgas
University Health Network
Maureen Griffiths
Ministry of Community Safety & Correctional Services – Emergency Management Ontario
Doris Grinspun
Registered Nurses Association of Ontario
Ann Gronski
Ontario Hospital Association
Sue Guinard
Ministry of Health and Long-Term Care – Long-Term Care Home Branch
John Hamilton
Ontario Association of Medical Laboratories
Jessica Harris
Ministry of Health and Long-Term Care – Emergency Management Unit
Christine Harrison
The Hospital for Sick Children
Justine Hartley
Ministry of Health and Long-Term Care – Emergency Management Unit
Laura Hawryluck
University Health Network
Karen Hay
Ministry of Health and Long-Term Care – Infectious Diseases Branch
Gilbert Heffern
Ontario Long-Term Care Association
Margaret Herridge
University Health Network
Gillian Howard
University Health Network
Sheree Hryhor
Toronto Emergency Medical Services
Lennox Huang
McMaster University Medical Centre
Patricia Huston
Ottawa Public Health
Lori Jacobs
Chiefs of Ontario
Carol Jacobson
Ontario Medical Association
Val Jaeger
Niagara Region Public Health Unit
Roma Jalali
Ministry of Health and Long-Term Care – Health Services I&IT Cluster
Tiffany Jay
Ministry of Health and Long-Term Care – Emergency Management Unit
Margo Jeffrey
Community Care Access Centre – Toronto
Barb Jennings
McMaster Children’s Hospital
Tony Jocko
Union of Ontario Indians
Beverly John
Joseph Brant Memorial Hospital
Nancy Johnson
Ontario Nurses Association
Tamara Johnson
St. Joseph Villa Nursing Home
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Ontario Health Plan for an Influenza Pandemic August 2008
Seema Jolly
Guelph General Hospital
Adam Jones
Clinidata/Telehealth
Charles Jones
Ministry of Health and Long-Term Care – Emergency Management Unit
Deanna Jones-Keeshig
Independent First Nations
Kathy Jovanovic
Peel Public Health
Debbie Kanate
First Nations and Inuit Health, Ontario Region
Neena Kanwar
Independent Diagnostic Clinics Association
Jan Kasperski
Ontario College of Family Physicians
Vatche Kelebozian
Ontario Retirement Communities Association
Ron Laxer
Hospital for Sick Children
Vahe Kehyayan
Ministry of Health and Long-Term Care – Psychiatric Patient Advocate Office
David Kelly
Ontario Federation of Community Health and Addictions Programs
Ed Kelly
Mount Sinai Hospital
Brendan Kilcline
Ontario Public Service Employees’ Union
James Kilgour
Region of Peel Corporate Services
Melissa Kimber
Hospital for Sick Children
Aviva Klompas
Ontario Hospital Association
Rodney Kort
Ministry of Health and Long-Term Care – Emergency Management Unit
Karim Kurji
Ministry of Health and Long-Term Care/York Region
Wendy Kuruliak
Hopital Regional de Sudbury Regional Hospital
Michael Kurup
Ministry of Health and Long-Term Care – Infectious Diseases Branch
Sudha Kutty
Ontario Hospital Association
Jeffrey Kwok
Ministry of Health and Long-Term Care – Community Health Branch
Claudia Lai
Ontario Public Drug Programs
Linda Lafrance
Nurse Practitioners’ Association of Ontario
Larry LaJambe
Ministry of Children & Youth Services
Brenda Lambert
St. Thomas Elgin-General Hospital
Shirley Lanza
Halton Healthcare Services
Ronald Laxer
Hospital for Sick Children
Neil Lazar
University Health Network
Colin Q-T Lee
Simcoe Muskoka District Health Unit
Yvonne Lee
Ontario Pharmacists’ Association
Lynn Leggett
Porcupine Health Unit
Janecka Lenka
Ontario Pharmacists’ Association
Holly Letheren
Ministry of Health and Long-Term Care – Infectious Disease Branch
Isra Levy
Ottawa Public Health Unit
Sue Lim
University Health Network
Bill Limerick
Northwestern Health Unit
Anne Longair
City of Toronto Hostel Services
Lori Lord
Ontario Home Care Association
Donald Low
Mount Sinai Hospital
Charlene Lunney
Ontario Association of Non-Profit Homes & Services for Seniors
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Ontario Health Plan for an Influenza Pandemic August 2008
Mary-Elle Luukkonen
Sault Area Hospital
Russell MacDonald
Ontario Air Ambulance Base Hospital Program
Valerie MacDonald
Ontario Nurses Association
Peggi Mace
Royal College of Dental Surgeons of Ontario – Federation of Regulated Health Professions Representative
Taryn MacKenzie
Ottawa Hospital
Marcia Macks Edwards
Independent Diagnostic Clinics Association
Sue MacLean
Telehealth
Elizabeth MacMillan-York
Sunnybrook Health Sciences Centre
Fiona Macpate
Ontario Safety Association for Community & Healthcare
Brenda MacPherson
Ontario Association of Community Care Access Centres
Elyse Maindonald
Nurse Practitioners’ Association of Ontario
Anna Majury
Ministry of Health and Long-Term Care – Laboratories Branch
Roy Male
Regent Park Community Health Centre / South Riverdale Community Health Centre
Allan Malek
Canadian Association of Chain Drug Stores
Tess Malolos
Ministry of Health and Long-Term Care – Communications & Information Branch
Nellie Manley
Mental Health and Addictions Branch
Val Mann
Northwestern Health Unit
Betsy Mandamin
Grand Council Treaty #3
Cathryn Mandoka
Association of Iroquois and Allied Indians
Val Mann
Northwestern Health Unit
Gordon Manning
Kingston General Hospital
Sharon Marsden
Ministry of Health and Long-Term Care – Home Care & Support Branch
Diane Martin
Ministry of Health and Long-Term Care – Nursing Secretariat
Laurie Martin
Clinidata Services Corporation
Anne Matlow
Hospital for Sick Children
Tony Mazzulli
Mount Sinai Hospital – Toronto Medical Laboratories
Diane McArthur
Ministry of Health and Long-Term Care – Human Resources Branch
Linda McCarey
Hastings & Prince Edward Counties Health Unit
Lisa McCaskell
Ontario Public Service Employees Union
Vicki McCoy
Board of Funeral Services
Beth McCracken
Registered Practical Nurses Association of Ontario
Allison McGeer
Consultant
Heather McGregor
Ministry of Health and Long-Term Care – Emergency Management Unit
Kimberley Meighan
The Hospital for Sick Children
Ian Mendelin
Ministry of Health and Long-Term Care – Emergency Management Unit
Mary Metcalfe
Oxford County Public Health
Greg Michener
Ministry of Health and Long-Term Care – Emergency Management Unit
Sandy Milakovic
Canadian Mental Health Association – Peel Branch
Dean Miller
Shoppers Drug Mart
Elaine Miller
Canadian Mental Health Association
Lisa Mills
Sudbury & District Health Unit
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Ontario Health Plan for an Influenza Pandemic August 2008
Golda Milo-Manson
Bloorview Kids Rehab
Maja Milosevic
Ministry of Health and Long-Term Care – Emergency Management Unit
Bill Mindell
Simcoe Muskoka District Health Unit
Robert Moore
Centre for Addictions and Mental Health
Nicola Morris
Consultant
Mary Mowbray
Mount Sinai Hospital
Marie Muir
Ministry of Health and Long-Term Care – Public Health Division
Michelle Mullen
Children’s Hospital of Eastern Ontario
Mathew Muller
St. Michael’s Hospital
Kellie Murphy
Mount Sinai Hospital
Roy Natividad
Ministry of Health and Long-Term Care, Individual Eligibility and Review Branch
Patrick Nelson
Ontario Medical Association
Geri Nephew
Toronto Public Health
Doug Nesrallah
Ministry of Community & Social Services
Christine Newman
The Hospital for Sick Children
David Nicholas
The Hospital for Sick Children
Marsha Nicholson
Homes for the Aged Division of Toronto Community & Neighbourhood Services
Heather Nicolson-Morrison
Ontario Funeral Service Association
Colleen Nisbet
Simcoe Muskoka District Health Unit
Linda Novotny
Acute Services & Chronic Disease Unit, Ministry of Health and Long-Term Care
Ellen Nowgesic
Nishnawbe-Aski Nation
Saida Nurmukhamedova
Ministry of Health and Long-Term Care, Emergency Management Unit
Sandy Nuttall
Ministry of Health and Long-Term Care- Hospitals Branch
Terry O'Donnell
Porcupine Health Unit
David Ogilvie
Ministry of Health and Long-Term Care – Emergency Management Unit
Heather Onyett
Queen’s University, Microbiology and Immunology
Caitriona O’Sullivan
Ministry of Health and Long-Term Care – Emergency Management Unit
Collette Ouellet
The Ottawa Hospital
Heather Oynett
Queen’s University
Elaine Pacheco
Toronto Public Health
Maggie Paiva
Peel Public Health
Penny Palmer
Ministry of Health and Long-Term Care- Hospitals Branch
Lucy Papineau
Mohawks of Akwesasne First Nation
Joan Park
St. Michael’s Hospital
Karen Parsons
Ministry of Health and Long-Term Care
Surabhi Patel-Widmeyer
Health Canada – First Nations and Inuit Health, Ontario Region
Lori Payne
Ontario Community Support Association
John Pereira
Halton Region Health Department – Emergency Medical Services
Ivan Peres
Ministry of Health and Long-Term Care – Health Professions Regulatory Policy & Programs Branch
Nancy Peroff-Johnson
Ministry of Health and Long-Term Care – Infectious Diseases Branch
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Ontario Health Plan for an Influenza Pandemic August 2008
Angelo Pesce
Ontario Association of Non-Profit Homes & Services for Seniors
Gary Petingola
Hôpital régional de Sudbury Regional Hospital
Jane Piccolotto
Ontario Community Support Association
Tony Pierro
Ontario Community Support Association
Carol Pitters
Ontario Medical Association
Laurie Poole
Clinidata Services Corporation
Rena Porteous
MINISTRY OF HEALTH AND LONG-TERM CARE-Midwifery
Susan Poutenan
Mount Sinai Hospital – Toronto Medical Laboratories
Addie Pryce
First Nations and Inuit Health
Douglas Pudden
Consultant
Alison Quigley
Child Health Network
Dianne Raby
Lanark, Leeds & Grenville Community Care Access Centre
Val Rachlis
Ontario College of Family Physicians
Stephan Ragaz
Peterborough Family Health Team
Seetha Raja
Ministry of Health and Long-Term Care – Primary Health Care Team
Lee Ramage
Hamilton Health Sciences Corporation
Lynne Raskin
South Riverdale Community Health Centre
Marilyn Reddick
Sunnybrook Health Sciences Centre
Carol Reeves
Management Board of Cabinet – Ontario Shared Services – Supply Chain Management
Anne Resnick
Ontario College of Pharmacists
Joanne Rey
Ministry of Health and Long-Term Care – Infectious Disease Branch
Doug Reycraft
Middlesex-London Health Unit
Donna Reynolds
Durham Region Health Department
Susan Richardson
The Hospital for Sick Children
Joseph Richer
Board of Funeral Services
Margaret Ringland
Ontario Association of Non-Profit Homes & Services for Seniors
Margaret Risk
Consultant
Judy Ritchie
Baycrest Centre for Geriatric Care
Anitta Robertson
Registered Nurses Association of Ontario
Jan Robinson
College of Physiotherapists of Ontario – Federation of Health Regulated Colleges of Ontario Rep.
Karie Robinson
Toronto Public Health
Eilyn Rodriguez
Ontario College of Family Physicians
Don Ross
Consultant
Mike Rosser
Healthcare Materials Management Services (London)
Maria Rugg
Hospital for Sick Children
Paula Ruppert
Ministry of Health and Long-Term Care – Mental Health & Addiction Branch
Jodie Russell
Timmins & District Hospital
Tina Sakr
Ministry of Health and Long-Term Care – Home Care & Community Support Branch
Deb Saltmarche
Ontario Pharmacists’ Association
Marina Salvadori
Children’s Hospital of Western Ontario
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Ontario Health Plan for an Influenza Pandemic August 2008
Lindy Samson
Children’s Hospital of Eastern Ontario
Dr. Danny Sapir
Halton Healthcare Services Corporation
Marty Sargent
Ministry of Health and Long-Term Care – Human Services I&IT Cluster
John Saunders
Canadian Red Cross
Tim Savage
Ontario Hospital Association
Bruce Sawadsky
ORNGE
Richard Schabas
Hastings & Prince Edward Counties Public Health Unit
Gordina Schellenberg
West Hill Community Health Centre
Frank Schmidt
Ministry of Health and Long-Term Care -Health Professions Regulatory Policy & Programs Branch
Brian Schwartz
Sunnybrook-Osler Centre for Prehospital Care; Ministry of Health and Long-Term Care Emergency Management Unit
Dianne Scoffield
Ministry of Community & Social Services
Maria-Luise Sebald
Ontario Long-Term Care Association
Karen Sequeira
Ontario Hospital Association
Matthew Sermer
Mount Sinai Hospital
Clint Shingler
Ministry of Health and Long-Term Care – Emergency Management Unit
Patricia Simone
Middlesex-London Health Unit
Mary Anne Simpson
Middlesex-London Health Unit
Jane Sinclair
Ontario Association of Non-Profit Homes & Services for Seniors
Terry Siriska
Ontario Hospital Association
Peter Slater
Consultant
Janine Small
Health Canada – Ontario / Nunavut Region – Communications, Marketing & Consultation Directorate
Patrick Smith
Hamilton Health Sciences Corporation
Kathryn Snell
Clinical Laboratory Management Association
Gordon Spear
Ontario Long-Term Care Association
Harry Spindel
Bayview Community Services Inc.
Sue Starling
Registered Nurses’ Association of Ontario
Danielle Steinman
Peel Public Health
Sophia Stephen
Ontario Medical Association
Janice Stewart
Princess Margaret Hospital – Haematology-Oncology Unit
Linda Stewart
Association of Local Public Health Agencies
Sarah Strasser
Sudbury & District Health Unit
Allison Stuart
Ministry of Health and Long-Term Care – Emergency Management Unit
Brenda Stuart
Consumer
Kathryn Suh
Children’s Hospital of Eastern Ontario
Kathy Suma
Ontario Long-Term Care Association – Extendicare
Christina Summers
Ontario Ministry of Health and Long-Term Care, Emergency Health Services Branch
Jeff Sumner
Gamma-Dynacare
Bev Sunohara
Ministry of Health and Long-Term Care- Supply & Financial Services Branch
Monir Taha
Halton Region Health Department
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Ontario Health Plan for an Influenza Pandemic August 2008
Susan Tamblyn
Consultant
Keith Tanswell
Hospital for Sick Children
Bill Teatero
Alternate Payment Programs Branch, Ministry of Health and Long-Term Care
Adrianna Tetley
Ontario Association of Community Health Centres
Edan Thomas
Midwives Collective of Toronto
Allison Thompson
Joint Centre for Bioethics- University of Toronto
Susan Thorning
Ontario Community Support Association
Ornella Tolomeo
Hamilton Public Health & Community Services
Gail Tomblin Murphy
Consultant
Barb Tomkinson
Ontario Retirement Communities Association
Stephanie Totten
Niagara Region Public Health Department
Baldwin Toye
The Ottawa Hospital
Catalina Trevizan
Ministry of Health and Long-Term Care – Human Services I&IT Cluster
Ellen Tsai
Kingston General Hospital
Heather Tyrell
Canadian Association of Chain Drug Stores
Ross Upshur
University of Toronto Joint Centre for Bioethics & Sunnybrook Health Sciences Centre
Christopher Usih
Toronto District School Board
Susan VanderBent
Ontario Home Care Providers Association
Suzanne Vanderlip
Markham Stouffville Hospital
Liz Van Horne
Ministry of Health and Long-Term Care – Strategic Planning & Implementation Branch
Pat Vanini
Association of Municipalities of Ontario
Peter Vaughan
Consultant
Mary Vearncombe
Sunnybrook Health Sciences Centre
Jennifer Veenboer
Ministry of Health and Long-Term Care – Emergency Management Unit
Joseph Verdirame
Ministry of Community Safety & Correctional Services – Emergency Management Ontario
Connie Verhaeghe
Hamilton Public Health & Community Services
Edith Vig
Ministry of Health and Long-Term Care, Emergency Management Unit
Mariella Vigneux
Grey Bruce Public Health Unit – Association of Local Public Health Agencies Representative
Andrea Volk
Ministry of Education-Ministry of Training, Colleges and Universities
Marilyn Wang
Ministry of Health and Long-Term Care – Health Professions Regulatory Policy & Programs Branch
Megan Ward
Peel Public Health Unit
Bryna Warshawsky
Middlesex-London Health Unit
Randy Wax
Mount Sinai Hospital
Phillipa Welch
Ontario Association of Non-Profit Homes & Services for Seniors
John Wellner
Ontario Medical Association
David White
Ontario College of Family Physicians
Georgina White
Ontario Association of Community Care Access Centres
Lindsay Whitmore
Ottawa Public Health
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Ontario Health Plan for an Influenza Pandemic August 2008
Leeann Whitney
North Bay Parry Sound District Health Unit
Jeff Wilbe
Addictions Ontario
Kathy Wilkie
College of Medical Laboratory Technologists of Ontario
David Williams
Ministry of Health and Long-Term Care. Public Health Division
Kristie Willson
Ministry of Health and Long-Term Care
Diane Wilson
Ontario Air Ambulance Services Co.
Anne-Luise Winter
Ministry of Health and Long-Term Care – Infectious Disease Branch
Petra Wolfbeiss
Association of Municipalities of Ontario
KK Wong
Ministry of Health and Long-Term Care – Human Services I&IT Cluster
Richard Wray
The Hospital for Sick Children
Jim Wrigley
Ministry of Health and Long-Term Care – Emergency Management Unit
Barbara Yaffe
Association of Local Public Health Agencies – Toronto Public Health
Hirotaka Yamashiro
Ontario Medical Association
Paul Zalan
Family Practice
Randi Zlotnik-Shaul
The Hospital for Sick Children
Dick Zoutman
Queen’s University
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Ontario Health Plan for an Influenza Pandemic August 2008
1. Background Every expert on influenza agrees that the ability of the influenza virus to reassort genes means that another pandemic not only can happen. It almost certainly will happen … influenza is among the most contagious of all diseases … the influenza virus can spread from person to person before any symptoms develop. If a new influenza virus does emerge, given modern travel patterns it will likely spread even more rapidly than it did in 1918. The Great Influenza, John M. Barry
1.1 Why Does Ontario Need a Plan for an Influenza Pandemic? During the 20th century, the world experienced three influenza pandemics. The most deadly, the "Spanish Flu" of 1918-19, killed 40 to 50 million people worldwide. Although no one can predict when the next influenza pandemic will hit, public health officials have warned that a global influenza pandemic is overdue. Appropriate planning for an influenza pandemic can reduce: the number of people infected (i.e., the extent of the outbreak), the amount of illness, the number of deaths, and the level of socio-economic disruption. Every jurisdiction must be prepared to mobilize resources quickly and effectively to limit the impact of an influenza pandemic.
1.2 About Influenza Influenza is a contagious respiratory illness caused by a group of viruses: influenza A, B, and C. Most seasonal influenza epidemics are caused by types A and B; type C rarely causes human illness. Influenza can cause mild to severe illness. It usually starts suddenly. Common symptoms include: fever (usually high, lasting 3 to 4 days); headache (often severe); aches and pains (often severe); fatigue and weakness (can last 2 to 3 weeks); extreme exhaustion (very common at the start);
Chapter #1: Background
stuffy nose; sneezing, sore throat, chest discomfort and cough; and nausea, vomiting and diarrhea (in children). A lot of different illnesses, including the common cold, can have similar symptoms.
Case Definition for Influenza Like Illness (ILI) in the General Population Acute onset of respiratory illness with fever and cough and with one ormore of the following - sore throat, arthralgia, myalgia, or prostration, which could be due to influenza virus. In children under 5, gastrointestinal symptoms may also be present. In patients under 5 or 65 and older, fever may not be prominent.
Source: Fluwatch (national case) While most healthy definition for the 2006-2007 season. people recover from influenza without complications, some people – such as older people, young children, and people with certain health conditions – are at high risk for serious complications from influenza. Some of the complications caused by influenza include: pneumonia (bacterial or viral), dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. Children and adults may develop sinus problems and ear infections.
A highly infectious disease, influenza is directly transmitted from person to person primarily when people infected with influenza cough or sneeze, and droplets of their respiratory secretions come into contact with the mucous membranes of the mouth, nose and possibly eyes of another person (i.e., droplet spread). Droplets expelled during coughing or sneezing can be inhaled by someone who is within two
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metres of the coughing or sneezing person (short-range transmission).
1.3 When Does Influenza Become a Pandemic?
Because the virus in droplets can survive for 24 to 48 hours on hard non-porous surfaces, for 8 to 12 hours on cloth, paper and tissue, and for 5 minutes on hands, it can also be transmitted indirectly when people touch contaminated hands, surfaces and objects, and then touch their face (i.e., contact spread).
Strains of influenza are Flu Terms circulating Seasonal (or annual) influenza is a contagious respiratory illness in humans that throughout the occurs every year. An annual vaccine is world all the available. time. When does Pandemic influenza is a global outbreak that a strain cause a occurs when a new influenza A virus emerges, pandemic? Only to which the population has little immunity, that has the capacity to spread easily from influenza A person to person and cause serious human viruses are illness. associated with pandemics. Influenza pandemics arise when all four of the following occur:
During certain health care procedures (e.g., intubating patients), droplets containing influenza virus may become aerosolized and can be spread through the air. The issue of whether influenza can also be spread by airborne transmission in situations other than during aerosol-generating procedures is controversial. Current scientific literature and experience with other influenza viruses does not conclusively confirm or rule out airborne transmission. (For more information about the risks of influenza transmission in health care settings, see Chapter 7 – Occupational Health and Safety and Infection Prevention and Control.) The incubation period for influenza is from 1 to 3 days. People with influenza may be able to transmit the virus for up to 24 hours before symptoms appear. Adults are infectious for 3 to 5 days after symptoms appear while children are infectious for up to 7 days after symptoms appear. People with influenza tend to shed more virus in their respiratory secretions in the early stages of the illness. Viral shedding tends to last longer in infants, young children and people with weak or compromised immune systems. Influenza is primarily a community-spread disease: that is, most transmissions occur in the community rather than in health care settings. Once the virus is widespread in the community, it becomes more difficult to stop or slow its spread.
Chapter #1: Background
• a novel influenza A virus emerges • the new virus can spread efficiently from human to human
• the new virus causes serious illness and death
• the population has little or no immunity to the new virus. The WHO (2005) suggests two mechanisms for the emergence of influenza viruses that cause pandemics:
• genetic reassortment, which occurs when two different viruses infect the same cell and exchange some gene segments. If the new virus can infect humans, cause serious disease, and spread easily from person to person, it can start a pandemic.
• adaptive mutation or stepwise changes in a virus, which occurs during sequential infection of humans or other mammals. The virus gradually changes to be more transmissible among humans. Most new influenza strains emerge in Southeast Asia where human populations have close interactions with pigs and domestic fowl. The probability of a new strain emerging in North America is relatively low.
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2. Roles, Responsibilities and Frameworks for Decision-Making To have any chance in alleviating the devastation of the [1918 influenza] epidemic required organization, coordination, implementation. It required leadership and it required that institutions follow that leadership. The Great Influenza, John M. Barry
Ontario’s health plan for an influenza pandemic is based on and reflects:
• the global pandemic planning phases developed by the World Health Organization (WHO)
• the Canadian pandemic planning phases developed by the Public Health Agency of Canada
• a collaborative approach to pandemic planning and direction provided by the Canadian Pandemic Influenza Plan
• emergency management and incident management systems used in Canada and Ontario
• an ethical framework to guide decisionmaking
• relevant provincial legislation. 2.1 WHO Pandemic Periods and Phases To help guide response planning for an influenza pandemic, the WHO has identified the phases of a pandemic.
Table 2.1: WHO Pandemic Periods and Phases Period
Interpandemic Period*
Pandemic Alert Period**
Pandemic Period Postpandemic Period
Phase
Description
Phase 1
No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. If present in animals, the risk* of human infection is considered to be low.
Phase 2
No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease.
Phase 3
Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact.
Phase 4
Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.
Phase 5
Larger cluster(s) but human-to-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible (substantial pandemic risk).
Phase 6
Increased and sustained transmission in general population. Return to interpandemic period
Source: World Health Organization, 2005. * The distinction between phase 1 and phase 2 is based on the risk of human infection or disease from circulating strains in animals. ** The distinction between phase 3, phase 4 and phase 5 is based on the risk of a pandemic.
Chapter #2: Roles, Responsibilities and Frameworks for Decision Making
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Ontario Health Plan for an Influenza Pandemic August 2008
2.2 Canadian Activity Levels The WHO phase number reflects the international risk or activity level with respect to the new influenza virus subtype, but it may not reflect virus activity in Canada especially during the pandemic alert period. To help guide pandemic planning and response in Canada, the Public Health Agency of Canada has developed a numbering system to reflect pandemic influenza activity in Canada:
• 0 indicates no activity in Canada • 1 indicates low activity and low risk in Canada
• 2 indicates higher activity and risk in Canada. The Canadian activity level number will be used with the WHO phase number to confirm the level of pandemic activity in Canada (see Table 2.2). The Ministry of Health and Long-Term Care and the local public health units will use the same indicators (no activity, low activity and higher activity) but without a numbering system to confirm pandemic activity in the province and at the local level.
2.3 A Collaborative Interjurisdictional Approach to Pandemic Planning Ontario’s plan is also based on coordination and collaboration among governments and jurisdictions. Because viruses do not respect borders, planning must occur: internationally, nationally, provincially and locally. The Role of Government Figure 2.1 (next page) illustrates the respective roles of different levels of government in pandemic planning. Each level of government has a different role depending on their jurisdictional authority, but their plans and activities must be coordinated. A coordinated collaborative approach will ensure effective communication between local health authorities (who will be the first to detect influenza in their communities) and the provincial and federal governments, with other countries, and with international health authorities.
Table 2.2: Example of WHO and Canadian Pandemic Activity Levels WHO Phase
CAN Phase
WHO/CAN Phase
Definition
6
0
6.0
Outside Canada increased and sustained transmission in the general population has been observed. No cases have been detected in Canada.
6
1
6.1
Single human case(s) with the pandemic virus detected in Canada. No cluster(s) identified in Canada.
6
2
6.2
Localized or widespread pandemic activity observed in the Canadian population.
Chapter #2: Roles, Responsibilities and Frameworks for Decision Making
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 2.1: Roles and Responsibilities in Collaborative Interjurisdictional Pandemic Planning
Chapter #2: Roles, Responsibilities and Frameworks for Decision Making
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Ontario Health Plan for an Influenza Pandemic August 2008
The Ontario Health Plan for an Influenza Pandemic is consistent with the Canadian Pandemic Influenza Plan (CPIP) and implements the activities set out in the federal plan. Ontario will continue to work closely with the Public Health Agency of Canada (PHAC) to plan its response to an influenza pandemic. In addition to government, other stakeholders will play a key role, including health care providers and their regulatory colleges and associations, and the public. Role of Health Services Each part of the health care system has a role to play in planning to respond to the population’s influenza-related needs as well as to maintain other critical health services (e.g., maternity care, trauma services, and treatment of life-threatening illnesses, chronic care, and palliative care). The steps that each part of the system will take during a pandemic are described in detail in Part III of the OHPIP. Role of Regulated Health Professions and Regulatory Colleges Health professionals and their regulatory colleges will play a key part in a consistent, coordinated provincial response to an influenza pandemic. They will help ensure effective communication within their profession, and high levels of professional respect and collaboration (based on a clear understanding of roles) among health professionals. As part of OHPIP, regulatory colleges are being encouraged to develop action plans consistent with the principles of the Regulated Health Professions Act (i.e., protection from harm, quality of care, access, accountability, equity, equality) and with the OHPIP ethical framework for decision-making framework (see 2.5). The plans will help Ontario provide the best care possible during a pandemic. They will also
encourage a consistent province-wide response that supports Ontario’s proposed competency-based approach to optimizing deployment of health care providers during a pandemic (see Chapter 8). These plans should consider the following issues: Communications
• appropriate communication strategies with staff, College Council, and members and accompanying infrastructure (e.g. web-based, telephone/teleconference; automated information services, fax, mail)
• the role of the Federation of Health Regulatory Colleges of Ontario
• collaboration with the Ministry of Health and Long-Term Care to develop a coordinated communications strategy. Regulatory
• accountability issues (where appropriate) • the need for regulatory colleges to develop complementary guidelines and/or policies for influenza care
• the need to develop co-ordinated policies on delegation
• the need for emergency (expedited) registration policies and standards for qualified individuals supported by appropriate regulations. Corporate
• co-operation among regulatory bodies and other stakeholders in planning for an influenza pandemic, including but not limited to, dissemination of information by jurisdiction (e.g., number of members in a given jurisdiction)
• co-operation on regulatory issues, such as the mobility and registration of health care providers, to facilitate a provincial response to an influenza pandemic
Chapter #2: Roles, Responsibilities and Frameworks for Decision Making
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Ontario Health Plan for an Influenza Pandemic August 2008
• the ability to maintain critical College operations during a pandemic (e.g., website or automated telephone messages)
• the ability to provide practice advice to members and employers 24/7 during a pandemic (e.g., website). Role of the Public The public is expected to actively participate in efforts to reduce the spread of the influenza, to comply with any public health measures, and to participate in their own care in a pandemic.
2.4 Emergency Management in Ontario An influenza pandemic will have an impact throughout society and will involve the broader emergency management system. The province’s health response will have to coordinate with Ontario’s emergency response. Figure 2.2 illustrates the relationship between Ontario’s health response to an influenza pandemic and the broader emergency response. Emergency management in Ontario and Canada is organized into five stages: prevention, mitigation, preparedness, response and recovery.
• Prevention involves activities taken to prevent or avoid an emergency or disaster. The eradication of smallpox is an example of a prevention strategy.
• Mitigation involves actions that can reduce the impact of an emergency or disaster. Influenza immunization and infection prevention and control measures are health-specific examples of mitigation. They will not prevent a
pandemic, but they will lessen its impact by reducing disease transmission.
• Preparedness involves measures that are put in place before an emergency occurs that will enhance the effectiveness of response and recovery activities, such as developing plans, tools and protocols; establishing communication systems; conducting training; and testing response plans.
• Response involves the coordinated actions that would be undertaken to respond to an emergency or disaster. In the case of the MOHLTC, this could involve a host of activities, including the mobilization of providers (hospitals, paramedics) and the coordination of health care services (isolation, treatment), and the acquisition and distribution of medical supplies and pharmaceuticals.
• Recovery involves activities that help communities recover from an emergency or disaster and return to a state of normalcy. This includes activities to repair damage, rebuild infrastructure, restore services, provide financial assistance and the ongoing treatment and care for the sick or injured. It may also include prevention/mitigation measures designed to avert a future emergency (e.g., vaccination to prevent a future outbreak). The recovery phase also applies to those involved in response who need time to recuperate and renew themselves. The activities described in this iteration of Ontario’s Health Plan for an Influenza Pandemic focus primarily on mitigation, preparedness and response. Plans for the recovery stage are still being developed.
Chapter #2: Roles, Responsibilities and Frameworks for Decision Making
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 2.2: Emergency Management Roles and Relationships
Note: For more detailed information on the make-up of the Ministry Emergency Operations Centre (MEOC), the Provincial Emergency Operations Centre (PEOC), see the Ministry of Health and Long-Term Care’s Emergency Plan on the ministry web site.
Chapter #2: Roles, Responsibilities and Frameworks for Decision Making
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Incident Management System (IMS) The Incident Management System is an international emergency management structure that has been adopted by Emergency Management Ontario (EMO) as the operational framework for emergency management for the Government of Ontario. It provides the basic command structure and functions required to manage an emergency situation effectively. The IMS has five components: Command, Operations, Planning, Logistics and Finance, and Administration. This simple structure can be applied to any organization involved in emergency management. It allows them to standardize contact information across organizations, which makes communication and cooperation among the groups easier, and the process of managing an emergency more efficient. By using IMS structure in a health emergency, staff are able to communicate directly with their peers in other health care settings and jurisdictions. For example, during an influenza pandemic, health organizations can use the IMS to help distribute medical supplies from federal and provincial stockpiles to the front line. In this case, the Logistics position in each organization would work with the Logistics function within the local public health unit to arrange distribution of supplies. The Ministry of Health and Long-Term Care will use this model for its Emergency Operations Centre (MEOC). Other organizations provincially and locally (e.g., acute care hospitals) are also using this model. Emergency Response Activities Emergency response is the broad range of activities required to respond to any emergency, including a health emergency, such as an influenza pandemic. It includes
measures to prepare for emergencies, such as developing and testing plans and establishing communication systems. It also includes the services provided during an emergency by emergency responders, such as police and firefighters, and by workers who provide critical community services, such as utility and telecommunications workers, and social service providers. A timely, comprehensive emergency response to an influenza pandemic requires:
• effective coordination/communication between the health and emergency response systems at all levels (i.e., federal, provincial, municipal)
• business continuity plans/continuity of operations plans to ensure continuity of critical services and infrastructure during a pandemic
• a mechanism to identify emergency response resources that can be mobilized to help respond to the health demands of a pandemic. Emergency response activities for a pandemic focus on building on the emergency plans already in place, in order to provide critical services for the pandemic (e.g., protecting workers in critical industries from exposure to influenza, providing critical services to people isolated in their homes, maintaining critical services when a significant proportion of workers may be ill with influenza). Emergency Management Ontario, in collaboration with other ministries, has developed a Provincial Coordinating Plan for an Influenza Pandemic (see: www.moh.gov.on.ca/pandemic). That plan addresses pandemic planning issues outside the health sector, and focuses on maintaining critical infrastructure and meeting Ontarians’ needs during a pandemic.
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During a pandemic, the health system may also need to call on emergency responders and other workers to assist in providing health services, transporting medical supplies and services, and ensuring the safety and security of vaccine and antiviral supplies.
2.5 Ethical Framework for Decision Making1 During an influenza pandemic, governments and public health authorities will have to make difficult decisions (e.g., access to vaccines and antivirals, reallocation of people and resources). Stakeholders (e.g., members of the public, patients, health care workers, other organizations) are more likely to accept the difficult decisions if the decision-making processes are:
• Open and transparent – The process by which decisions are made must be open to scrutiny and the basis for decisions should be explained.
• Reasonable – Decisions should be based on reasons (i.e., evidence, principles, values) and be made by people who are credible and accountable.
• Inclusive – Decisions should be made explicitly with stakeholder views in mind and stakeholders should have opportunities to be engaged in the decision-making process.
• Responsive – Decisions should be revisited and revised as new information emerges, and stakeholders should have opportunities to voice any concerns they have about decisions (i.e., dispute and complaint mechanisms).
• Accountable – There should be mechanisms to ensure that ethical
decision-making is sustained throughout the response. As noted by Justice Campbell in the final report of the SARS Commission (Spring of Fear, December 2006) we cannot always wait for scientific certainty before we take reasonable steps to reduce risk. Once an influenza pandemic emerges, outbreaks will spread rapidly across the globe and scientific evidence on the characteristics and epidemiology of the novel virus will be limited in the early stages. As a result, decision-making processes will apply the precautionary principle when there is scientific uncertainty. Ontario’s response to an influenza pandemic will be based on the following core ethical values (not listed in priority order). More than one value may be relevant in any given situation, and some values will be in tension with others. This tension is the cause of the ethical dilemmas that may emerge during a pandemic, and reinforces the importance of shared ethical language as well as decision-making processes that can assign a moral weight to each value when values are in conflict. Individual Liberty. Individual liberty (i.e., respect for autonomy) is a value enshrined in our laws and in health care practice. During a pandemic, it may be necessary to restrict individual liberty in order to protect the public from serious harm. Individual liberty can be preserved to the extent that the imposed limits and the reasons for them are transparent. Restrictions to individual liberty will:
• be proportional to the risk of public harm • be necessary and relevant to protecting the public good
• employ the least restrictive means
1 Adapted from: Stand on Guard for Thee: Ethical considerations in preparedness planning for pandemic influenza. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group, November 2005. http://www.google.ca/search?hl=en&q=Stand+on+Guard+for+Thee&btnG=Google+Search&meta=
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necessary to achieve public health goals
• be applied without discrimination. Protection of the Public from Harm. Public health authorities have an obligation to protect the public from serious harm. For public health to fulfill this obligation and minimize serious illness, death and social disruption, public health may isolate people or use other containment strategies, and/or require health care facilities to restrict public access to some areas or limit some services. For these protective measures to be effective, citizens must comply with them. The ethical value of individual liberty is often in tension with the obligation to protect the public from harm; however, it is also in individuals’ interests to serve the public good and minimize harm to others. When making decisions designed to protect the public from harm, public health authorities will:
• weigh the benefits of protecting the public from harm against the loss of liberty of some individuals (e.g., isolation)
• ensure all stakeholders are aware of the medical and moral reasons for the measures, the benefits of complying, and the consequences of not complying
• establish mechanisms to review decisions as the situation changes and to address stakeholder concerns or complaints. Proportionality. Restrictions on individual liberty and measures to protect the public from harm should not exceed the minimum required to address the actual level of risk or need in the community. Ontario will:
• use the least restrictive or coercive measure possible when limiting or restricting liberties or entitlements
• use more coercive measures only in circumstances where less restrictive means have failed to achieve appropriate [public health] ends.. Privacy. Individuals have a right to privacy, including the privacy of their health information. During a pandemic, it may be necessary to balance the right to privacy with the responsibility to protect the public from serious harm; however, to be consistent with the ethical principle of proportionality, Ontario will:
• determine whether the good intended is significant enough to justify the potential harm of suspending privacy rights (e.g., potential stigmatization of individuals and communities)
• require private information only if there are no less intrusive means to protect public health
• limit any disclosure to only that information required to achieve legitimate public health goals
• take steps to prevent stigmatization (e.g., public education to correct misperceptions about disease transmission). Note: Where the plan contains any reference to the collection, use or disclosure of information or data, it is referring to nonidentifiable information or data whenever possible. Any collection, use or disclosure of personal information will be done in compliance with governing legislation, including the Personal Health Information Protection Act, 2004. Equity. All patients have an equal claim to receive the health care they need, and health care institutions are obligated to ensure sufficient supply of health services and materials. During a pandemic, tough decisions may have to be made about who will receive antiviral medication and vaccine
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if they are in short supply, and which health services will be temporarily suspended. Depending on the extent of the pandemic, measures taken to contain the spread of disease may limit access to emergency or critical services. In these circumstances, decision makers will:
• strive to preserve as much equity as possible between the needs of influenza patients and patients who need urgent treatment for other diseases
• establish fair decision-making processes/criteria. Duty to Provide Care. Health care workers have an ethical duty to provide care and respond to suffering. During a pandemic, demands for care may overwhelm health care workers and their institutions, and create challenges related to resources, practice, liability and workplace safety. Health care workers may have to weigh their duty to provide care against competing obligations (i.e., to their own health, family and friends). When providers cannot provide appropriate care because of constraints caused by the pandemic, they may be faced with moral dilemmas. To support providers in their efforts to discharge their duty to provide care, Ontario will:
• work collaboratively with stakeholders, regulatory colleges and labour associations to establish practice guidelines
• work collaboratively with stakeholders, including labour associations, to establish fair dispute resolution processes
• strive to ensure appropriate supports are in place (e.g., resources, supplies, equipment)
• develop a mechanism for provider complaints and claims for work exemptions. Reciprocity. Society has an ethical responsibility to support those who face a disproportionate burden in protecting the public good. During a pandemic, the greatest burden will fall on public health practitioners, other health care workers, patients, and their families. Health care workers will be asked to take on expanded duties. They may be exposed to greater risk in the workplace, suffer physical and emotional stress, and be isolated from peers and family. Individuals who are placed in isolation may experience significant social, economic, and emotional burdens. Decisionmakers will:
• take steps to ease the burdens of health care workers, patients, and patients’ families. Trust. Trust is an essential part of the relationship between government and citizens, between health care workers and patients, between organizations and their staff, between the public and health care workers, and among organizations within a health system. During a pandemic, some people may perceive measures to protect the public from harm (e.g., limiting access to certain health services) as a betrayal of trust. In order to maintain trust during a pandemic, decision-makers will:
• take steps to build trust with stakeholders before the pandemic occurs (i.e., engage stakeholders early)
• ensure decision making processes are ethical and transparent. Solidarity. Stemming an influenza pandemic will require solidarity among community, health care institutions, public health units, and government. Solidarity requires good, straightforward
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2.6 Relevant Provincial Legislation
communication and open collaboration within and between these stakeholders to share information and coordinate health care delivery. By identifying the health of the general public and health care workers as resources worth protecting, these stakeholders can model values of solidarity and encourage others to broaden traditional ethical values focused on the rights or interests of individuals.
During a pandemic, individuals and institutions responsible for managing the response will require the legal authority to implement pandemic plans. Much of that legislation is already in place (e.g., the Health Protection and Promotion Act, the Emergency Management and Civil Protection Act). During pandemic planning and during a pandemic, Ontario will work within a legal framework that attempts to balance the rights of individuals (e.g., privacy, liberty, equity) with the responsibility to protect the public from harm and the rights of workers to work in safety. The following legislation will guide Ontario’s response to a pandemic.
Stewardship. In our society, both institutions and individuals will be entrusted with governance over scarce resources, such as vaccines, antivirals, ventilators, hospital beds and even health care workers. Those entrusted with governance should be guided by the notion of stewardship, which includes protecting and developing one’s resources, and being accountable for public well-being. To ensure good stewardship of scarce resources, decision makers will:
Emergency Legislation The Emergency Management and Civil Protection Act (EMCPA) is the principle statute governing emergency management in Ontario. It governs all municipalities, ministers presiding over a provincial ministry, and agencies, boards, commissions and other branches of the provincial government designated by the Lieutenant Governor in Council. Under the Act:
• consider both the benefit to the public good and equity (i.e., fair distribution of both benefits and burdens). Family-centred Care. The health system will respect a family’s right to make decisions on behalf of a child, consistent with the capacity of the child. Health care providers will respect families’ unique beliefs and values, and acknowledge that their choices will be informed by their beliefs and values.
• a head of municipal council may declare that an emergency exists in the municipality and may take action and issue orders to implement the emergency plan of the municipality and to protect property and the health, safety and welfare of the inhabitants of the emergency area
Respect for Emerging Autonomy. When providing care to young people, the health system will respect their emerging autonomy, and disclose age appropriate information. Ontario will use this ethical framework to guide decision-making in pandemic planning and management.
• the Premier may at any time declare that an emergency has been terminated
•
the Cabinet or the Premier, if in the Premier’s opinion the urgency of the situation requires that an order be made immediately, may declare that an emergency exists throughout Ontario or in any part thereof
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•
a provincial order declaring an emergency must satisfy declaration criteria as set out within the Act
•
an emergency is terminated 14 days following its declaration and can be extended for an additional 14-day period by Cabinet; the Legislative Assembly can vote to extend the period for additional periods of up to 28 days
•
during an emergency, Cabinet may issue any of 14 types of orders according to strict criteria and limitations; these include : •
implementing emergency plans
•
regulating or prohibiting travel or movement
•
establishing facilities such as emergency shelters and hospitals
•
closing any place, whether public or private
•
authorize facilities, such as electrical generating facilities, to operate as necessary
•
using and making available any necessary goods, services and resources
•
fixing prices for necessary goods, services and resources and prohibiting price gouging
•
authorize those who would not otherwise be eligible to do so, to perform certain duties (e.g., allowing doctors from other jurisdictions to work in Ontario for the duration of the declared provincial emergency)
•
requiring any person to collect, use or disclose information that may be necessary to respond to the emergency
• heads of municipal councils and ministers presiding over a provincial
ministry and designated agencies, boards, commissions and branches of government are required to develop and implement emergency management programs which must consist of: •
an emergency plan
•
training programs and exercises for municipal and Crown employees and other persons
•
public education
•
any other element required by regulation.
• heads of municipal councils and ministers presiding over a provincial ministry and designated agencies, boards, commissions and branches of government are also required to identify and assess the various hazards and risks to public safety that could give rise to emergencies and identify the facilities and other elements of the infrastructure for which they are responsible that are at risk of being affected by emergencies Pursuant to Order-in-Council 2291/2004 (December 8, 2004), the Minister of Health and Long-Term Care is responsible for two areas in formulating emergency plans: human health, disease and epidemics; and provision of health services during an emergency (e.g., floods, ice storm). Public Health Legislation The Health Protection and Promotion Act (HPPA) is the primary statute governing the organization and delivery of public health programs and services, the promotion and protection of the health of the people of Ontario, and the prevention of the spread of disease. Under the HPPA:
• physicians, laboratories, school principals and others must report certain diseases, including influenza to medical officers of health
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• persons who pose a risk to the public
A number of amendments to the Health Protection and Promotion Act provide new powers to the Minister and Chief Medical Officer of Health (CMOH), which may be invoked without the declaration of a provincial emergency. These powers are intended to mitigate an incident such as an outbreak of infectious disease from escalating to the level of a provincial emergency. These additional powers include:
health may be ordered to do, or to stop doing anything to reduce the risk of disease transmission
• information about patients who are infected with communicable diseases must be disclosed to the medical officer of health, while protecting the confidentiality of sensitive health information
• physicians and registered nurses in the extended class are required to report to the medical officer of health the name and residence address of any person who is under the care and treatment of the physician/nurse in respect of a communicable disease and who refuses or neglects to continue the treatment in a manner and to a degree satisfactory to the physician
• upon investigation, appropriate action may be taken by the Chief Medical Officer of Health to prevent, eliminate or decrease a health risk
•
authorizing the Minister of Health and Long-Term Care upon certification of the Chief Medical Officer of Health to procure, acquire or seize medications and supplies (subject to reasonable compensation) when regular supply and procurement processes are insufficient to address the needs of Ontarians
•
authorizing the Chief Medical Officer of Health to: •
request information from health information custodians
•
collect, retain and use pre-existing laboratory specimens to investigate, eliminate or reduce the risk to health
•
issue directives concerning precautions and procedures to health care providers
• under certain conditions, premises may be required to be used as temporary isolation facilities. The Health System Improvements Act, 2007 On June 4, 2007, Ontario passed the Health System Improvements Act, which amended the Health Protection and Promotion Act as well as a number of other health statutes. The Ontario Agency for Health Protection and Promotion Act, 2007 was also passed as a Schedule to this Act. The Ontario Agency for Health Protection and Promotion Act, 2007 established the Ontario Agency for Health Protection and Promotion, which, once developed, will play a key role within the ministry’s emergency management program as well as provide critical support to the ministry’s response to future emergencies.
A number of additional amendments have been made in order to strengthen the capacity of Ontario’s public health system to respond to outbreaks of disease. These include:
• increased powers for local Medical Officers of Health to investigate and respond to outbreaks of communicable disease in hospitals
• increased timeliness and efficiency of laboratory reporting of reportable diseases
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• improved enforcement of public health orders Note: some provisions of the new Act are already in force; others will come into force on a date to be named by proclamation of the Lieutenant Governor. The Occupational Health and Safety Act The Ministry of Labour enforces the Occupational Health and Safety Act (OHSA) and the Health Care and Residential Facilities Regulation (HCRF). Under the OHSA, an employer has the duty to take all reasonable precautions in the circumstances for the protection of a worker. Further, under the HCRF Regulation, there is a duty for employers in health care facilities to establish measures and procedures including the following:
• control of infections • immunization • the use of disinfectants • the handling, cleaning and disposal of soiled linen, sharp objects and waste. Employers, in The OHSA cannot be consultation overridden by any with the Joint emergency order made Health and under either the Safety EMCPA or the HPPA. Committee (JHSC) in the workplace, are required to develop these procedures and provide workers with relevant training. Workers have the right to participate in identifying and resolving workplace health and safety concerns, and have a duty to wear and use protective equipment, devices or clothing provided by the employer.
2.7 Additional Provincial Health Legislation Pre-Hospital Care Legislation The Ambulance Act is the principal statute governing the operation of land and air emergency medical services and the provision of pre-hospital emergency health care in the Province of Ontario. The Land Ambulance Service Patient Care and Transportation Standards Revised October 2002 (incorporated by reference into the regulations under the Ambulance Act) deal in part with communicable disease management and influenza control. The provisions concerning communicable disease management during a communicable disease outbreak impose a number of obligations on ambulance service operators, including:
• the education of paramedics respecting communicable disease risks;
• ensuring appropriate protection and infection control measures for paramedics; and
• reporting to the Ministry of possible exposure by a paramedic of a communicable disease. The provisions concerning influenza control impose more specific obligations on operators concerning influenza outbreaks, including:
• annual educational reviews for paramedics on protection from and transmission of influenza
• immunization of paramedics • where a paramedic has not been immunized, removal of the paramedic from patient care duties during a declared influenza outbreak or, during an emergency and where no other qualified paramedic is available, the requirement for the unimmunized
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paramedic to adopt specified protective measures. Hospital Legislation Under the Public Hospitals Act:
• hospitals are required to obtain ministry approval before using additional sites for hospital services (Note: this may have implications for Influenza Assessment, Treatment and Referral Centres that are planning to provide services usually offered in hospital.)
• Cabinet is authorized to appoint a hospital supervisor on the recommendation of the Minister of Health and Long-Term Care
• the Minister is authorized to make regulations, subject to Cabinet approval, to address the safety of any hospital site and to deal with patient admissions, care and discharge
• the hospital board is required to ensure the administrator, medical staff, chief nursing executive, staff nurses and nurses who are managers develop plans to deal with: (i) emergency situations that could place a greater than normal demand on the services provided by the hospital or disrupt the normal hospital routine, and (ii) the failure to provide services by persons who ordinarily provide services in the hospital. Under the Private Hospitals Act:
• private hospitals are required to obtain ministry approval before constructing or adding to, altering or renovating a private hospital building or enlarging the patient bed capacity of a private hospital building
• private hospitals are required to be used for the treatment only of the number of patients permitted by the license, except in the case of emergency; only for
purposes in respect of which the license is issued; and only for patients of a class permitted by the license
• Cabinet is authorized to make regulations considered necessary for the alteration, safety, equipment, maintenance and repair of private hospital sites; the management, conduct, operation and use of private hospitals; prescribing the type and amount of surgery, gynaecology or obstetrics that may be preformed in any class of private hospital and the facilities and equipment that shall be provided for such purposes; the admission, treatment, care, conduct, discipline and discharge of patients; and the classification of patients. Other Facility Legislation The Nursing Homes Act, the Charitable Institutions Act, and the Homes for the Aged and Rest Homes Act (which govern long-term care facilities in Ontario until the coming into force of the Long-Term Care Homes Act) in conjunction with the service agreements entered into with these operators require the operators of long-term care facilities to:
• implement surveillance protocols for a particular communicable disease provided by the MOHLTC
• report all communicable disease outbreaks to the medical officer of health
• comply with the Long-Term Care Facility Program Manual
• provide information to the MOHLTC relating to the operation of the facility (e.g., bed occupancy rates, service levels, staffing levels). Legislation Governing Community Health Services The Long-Term Care Act and the Community Care Access Corporations Act, in conjunction with the memorandum of
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understanding and funding agreements between the ministry and community-based agencies, give the ministry the authority to require CCACs and other approved community-based agencies to:
• provide reports and information • comply with all ministry directives, policies, guidelines and procedures, including surveillance protocols for communicable diseases
• comply with the most recent Planning, Funding and Accountability Manual. Legislation Governing Health Information The Personal Health Information Protection Act, 2004. That Act, effective November 1, 2004, governs the collection, use, and disclosure of personal health information by health information custodians, including physicians, hospitals, long-term care facilities, boards of health, medical officers of health and the Ministry of Health and Long-Term Care. It includes:
• provisions providing for the disclosure of personal health information to the Chief Medical Officer of Health or a medical officer of health by health information custodians without the consent of the individuals to whom the information relates where the information is disclosed for a purpose of the Health Protection and Promotion Act.
• provisions providing for the disclosure of personal health information by health information custodians – without the consent of the individuals to whom the information relates – to public health authorities in other jurisdictions where the disclosure is made for a purpose that is substantially similar to a purpose of the Health Protection and Promotion Act.
Legislation Governing Regulated Health Professionals Under the authority of the Regulated Health Professions Act, 1991 (RHPA), the power to register physicians, nurses and other regulated health professionals is provided to the College which governs the health profession, not the Ministry of Health and Long-Term Care. Temporary registration in the event of an emergency is possible under the RHPA, the Health Professions Procedural Code (Code), which is Schedule 2 to the RHPA and the health profession specific Acts. See, for example, the registration regulations made under the Medicine Act, 1991, Nursing Act, 1991 and the Medical Laboratory Technology Act, 1991. Specific requirements and procedures for temporary registration vary from College to College under their registration regulations. Depending on the provisions within the Colleges’ registration regulations, temporary registration of a regulated health professional in an emergency situation may be available. Under Regulation 865/93 – Registration, made by the College of Physicians and Surgeons of Ontario (CPSO), a certificate of registration may be issued for supervised, short duration practice without first requiring an order of the CPSO’s Registration Committee. In these circumstances, the appointment must be for the purpose of providing, among other things, medical services for a short interval that would otherwise be unavailable due to a lack of persons to provide them. The applicant must also meet all the criteria under the regulation relating to supervised practice of short duration. The certificate expires thirty days after it is issued unless a panel of the Registration Committee orders an extension. Some Colleges may be unable to issue temporary certificates in emergency circumstances. Under the Code, a College
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Registrar may grant a certificate of registration with terms and conditions, for example, limiting the time or location of the professional’s practice, but only with the approval of a panel of the Registration Committee. Other Colleges have developed expedited processes for use in emergency circumstances.
2.8
Federal Emergency Legislation
Three federal statutes are important to the province and to the ministry during an emergency. The Emergency Management Act (EMA), which came into force on August 3rd, 2007. provides the federal framework for emergency management, similar to Ontario’s EMCPA. This includes the respective roles and responsibilities of the Minister of Public Safety and other federal Ministers for emergency planning and response. Under the EMA:
• the Minister of Public Safety is responsible for providing leadership and coordination among government institutions and with the provinces regarding emergency management activities
• other federal Ministers are required to develop, maintain and test emergency management plans and to provide the requisite training and exercises on those plans.
• the federal government is required to coordinate emergency preparedness and response activities with provincial governments, including providing financial assistance to provinces when requested.
• the federal government “may not respond to a provincial emergency unless the government of the province requests assistance or there is an
agreement with the province that requires or permits the assistance.” The federal Emergencies Act governs the response to “national emergencies”. National emergencies are considered to be urgent and critical situations of such proportions that they exceed the capacity or authority of a province or they seriously threaten the security or sovereignty of the country. They are broken down into the following categories:
• public welfare emergencies • public order emergencies • international emergencies • war emergencies. A severe health emergency such as an influenza pandemic would fall in the category of public welfare emergencies. Similar to Ontario’s EMCPA, the Emergencies Act governs the declaration, expiration and continuation and revocation of each type of emergency and the emergency orders that may be issued under each circumstance. Examples of emergency orders include:
• regulation or prohibition of travel • evacuation of persons • appropriation of property • authorization or direction to persons to render essential services
• the regulation of essential goods, services and resources
• the establishment of emergency shelters and hospitals
• the authorization of expenditures. The Act also provides for compensation to persons who suffer loss, injury or damage as a result of any of order issued by the government under the Act. The Quarantine Act gives the federal
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government general and emergency powers to inspect, issue orders and enforce quarantine on travellers and cargo arriving in Canada for the purpose of preventing the introduction and spread of communicable diseases.
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3. Planning Goals, Approach and Assumptions [E]pidemiologists, scientists, public health officials, and ethicists will have to join with the professionals who handle disasters. Some of the issues are obvious and simple, such as making sure health care workers are the first to get vaccinated. … Other questions involve logistics and risk assessment. Some elements … involve questions of power and ethics. Public health officials will need the authority to enforce decisions. … Questions about who will have the authority to make and ensure decisions, and under what circumstances, must be settled in advance. The Great Influenza, John M. Barry
3.1 Goals 1.
2.
To minimize serious illness and overall deaths through appropriate management of Ontario’s health care system, and To minimize societal disruption in Ontario as a result of an influenza pandemic.
The focus of pandemic planning is to reduce the impact of influenza on individuals and society.
3.2 Strategic Approach Ontario’s Health Plan for an Influenza Pandemic is based on a four-pronged strategic approach: Be ready. Plan at the provincial and local levels in anticipation of an influenza pandemic. Be watchful. Practise active screening and surveillance to identify the earliest signs of an influenza pandemic. Be decisive. Manage the spread quickly and effectively. Be transparent. Communicate with Ontarians. Be Ready: Plan at the Provincial and Local Levels for an Influenza Pandemic Ontario will make every effort to develop a plan which ensures the province is ready to deal with as many eventualities as possible.
The plan will be continually updated to reflect new potential challenges and the most current thinking. Pandemic planning will identify those activities that are critical for the well-being of the province. It will also identify less critical activities that can be curtailed to free up resources for critical activities. The process of making these types of decisions and developing plans will be based on the ethical framework (see Chapter 2). Planning will identify the additional resources – human and physical – required at the provincial and local levels to provide critical services, and establish a process to make those resources available. The role of the Public Health Division (PHD) and Emergency Management Unit (EMU), along with the other divisions and branches at the MOHLTC, is to plan and prepare for a possible influenza pandemic or any infectious disease that may arise. They will also provide direction, guidance, and support to local public health units with their pandemic planning initiatives. Plans will be tested at the local, provincial and national levels to identify any gaps, overlaps or confusion that can be corrected, and to reassure the public that Ontario has effective plans in place and will be able to respond to an influenza pandemic.
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Be Watchful: Screening and Surveillance Ontario will identify clusters of respiratory infection early. In addition to routine influenza surveillance, the MOHLTC has established an active screening and surveillance program – an early warning system – that will identify individuals with febrile respiratory illness (FRI) – including influenza like illness (ILI) – early. As part of its effort to be watchful, Ontario will closely monitor influenza or influenzalike illness outbreaks in other jurisdictions. Depending on where the pandemic strain of influenza originates, Ontario will use every opportunity to enhance and target its screening and surveillance systems. The province will also use any lead time to encourage the federal government to increase screening and surveillance activities at border crossings and arrival points. Ontario will reinforce the importance of personal watchfulness. The province, in collaboration with local public health units and other stakeholders, will educate both health care workers and the public about their role in identifying signs of influenza and preventing its spread. Be Decisive: Manage the Spread Faced with an influenza pandemic, Ontario will act decisively to manage and contain its spread. While an influenza pandemic may be inevitable, Ontario can take steps to minimize its impact and protect the population, including providing vaccines and antiviral medications as available, curtailing public gatherings and limiting travel as appropriate. Be Transparent: Communicate with Ontarians To manage an influenza pandemic, the health care system must have the cooperation of the public and workers involved in pandemic influenza response.
As noted in the ethical framework for decision-making (see Chapter 2), that cooperation is based on trust and transparency. Decision-makers will enter into a covenant with the people of Ontario to be transparent and to provide the best available information. Ontarians will be informed about the plans, and consistent spokespersons will be identified to communicate with the public and address their questions during a pandemic. In return, Ontarians will be urged to comply with the advice, direction and, if required, the legal orders given by people responsible for managing the pandemic.
3.3 Planning Assumptions The Ontario Health Plan for an Influenza Pandemic is based on the following planning assumptions: The course of an influenza pandemic • A pandemic will be due to a new subtype of influenza A
• A new strain is most likely to occur in southeast Asia
• Ontario will have little lead time between when a pandemic is first declared by the WHO and when it spreads to the province
• An influenza pandemic usually spreads in two or more waves, either in the same year or in successive years. A second wave may occur within three to nine months of the initial outbreak wave and may cause more serious illnesses and deaths than the first. In any locality, the length of each wave of illness is approximately eight weeks.
• The pandemic strain will be primarily
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community spread: that is, transmitted from person to person in the community rather than in health care settings.
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The extent and severity of illness • Because the population will have had limited prior exposure to the virus, most people will be susceptible. If the pandemic is caused by a recycled influenza strain, children and otherwise healthy adults may be at greater risk because elderly people may have some residual immunity from previous exposure to a similar virus.
• Regardless of the severity of the pandemic, there will be an illness attack rate of 35%, which means that over the entire course of a pandemic about 35% of the population will be sick enough with influenza to take at least a half day off work.
• At the peak of the first wave, about 20 to 25% of the workforce will be absent from work for at least a half-day.
• About 45% of people who become ill during a moderately severe pandemic will not require medical care, but they will need health information and advice; about 53% will require outpatient or primary care (e.g., antiviral treatment); and approximately 1.5 to 2% will require hospitalization.
• More severe illness and mortality than
• Individuals who recover from illness with the pandemic strain will be immune to infection from that strain. Table 3.1 summarizes the estimated impact of an influenza pandemic of moderate severity on deaths, hospitalizations and outpatient visits at different attack rates in Ontario. The attack rates describe the impact over the entire duration of the pandemic, that is: the proportion of the population that will be infected over the multiple waves of influenza that usually occur during a pandemic. (Note: these estimates do not take into account the potential impact of antiviral drugs or an effective vaccine.) Access to antivirals/vaccine • The only specific treatment option for influenza during a pandemic will be antiviral drugs, which are most effective when started within 12 to 24 hours of onset of symptoms and must be started within 48 hours. The efficacy of antivirals against the pandemic strain is unknown but, when antivirals are used to treat seasonal influenza, they have been shown to reduce the length of time people are ill, risk of complications and hospitalizations.
• The federal and provincial governments will stockpile antivirals. (Ontario currently has an antiviral stockpile large enough to treat 25% of the population which should be large enough to provide treatment to anyone who needs it.)
the usual seasonal influenza is likely in all population groups.
• In the first pandemic wave, at least one third of deaths are likely to be in people under age 65 compared to less than 5% of deaths in interpandemic years.
• Although antivirals can be used for
• Subclinical infections will occur. Based on previous pandemics, many people will only experience mild illness or have no symptoms, but still be able to transmit the virus to others.
Chapter #3: Planning Goals, Approach and Assumptions
prophylaxis (i.e., preventing influenza), there will not be adequate supplies to provide both treatment and prophylaxis for everyone at this time. (Ontario will develop a provincial policy on the use of antivirals for prophylaxis after consideration of the national policy, which is currently under development.)
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Table 3.1: Estimated Impact of an Influenza Pandemic by Attack Rate (based on a moderate scenario - 1957-like virus) Attack Rate 15 % Source
min
Most likely
Attack Rate 25 % max
Most likely
min
Attack Rate 35% max
min
Most likely
1. Estimated 2001 Census population 2006
12,919,600
12,919,600
12,919,600
2. No. of people ill % of total enough to remain population home (1)
1,937,940
3,229,900
4,521,860
3. No. of people who can be #2 minus 4, managed through 5 and 6 self care
1,121,724
875,719
417,930
1,869,539 1,459,532
max
696,550
2,617,354
2,043,345
975,170
1,340,807 1,722,363 2,469,240
1,877,130
2,411,308
3,456,936
4. No. of people who will require FluAid 2.0 an outpatient visit
804,484
5. No. of people hospitalized who FluAid 2.0 will recover
8,595
23,388
29,525
14,325
38,979
49,208
20,055
54,572
68,892
6. No. of fatal cases FluAid 2.0 (70% in hospital)
3,137
5,415
8,941
5,229
9,026
14,902
7,321
12,635
20,862
10,791
27,179
35,784
17,985
45,297
59,639
25,180
63,417
83,495
7. No. of hospitalizations #5 plus 70% (recoveries + 70% of #6 of fatal cases)
1,033,418 1,481,544
Table 3.2: Number of People Affected as a Percentage of the Population (based on a 35% attack rate)
No. of People
% of People % of Total who are Population Clinically Ill (#1 in Table 3.1) (#2 in Table 3.1)
People who can be managed through self care
2,043,345
45.2%
15.8%
People who will require an outpatient visit
2,411,308
53.3%
18.7%
People who will be hospitalized and recover
54,572
1.2%
0.4%
Fatal cases (70% in hospital)
12,635
0.3%
0.1%
Hospitalizations (recoveries + 70% of fatal cases)
63,417
1.4%
0.5%
Note: Table 3.2 is based on the Meltzer model (developed at the Centers for Disease Control, Atlanta USA), which is also used by the Canadian Pandemic Influenza Plan. The model is based on the following assumptions: the numbers display a pandemic of mild to moderate severity and reflect the impact of the entire duration of the pandemic (i.e., multiple waves). The model does not include the potential impact of antiviral drugs, public health measures or an
Chapter #3: Planning Goals, Approach and Assumptions
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Ontario Health Plan for an Influenza Pandemic August 2008 effective vaccine. As Meltzer himself notes, “The wide range of values for most of the results adds emphasis to the fact that the impact of the next influenza pandemic is largely unknown.” The model is intended to show discrete or mutually exclusive health outcomes of outpatient care, hospitalization and death. However, during a pandemic, there is potential for a single patient to traverse through multiple outcomes (e.g., a patient who is hospitalized and dies; a patient who receives an outpatient visit and then dies at home). Therefore, the estimate for the number of persons who can be managed through self-care may be underestimated. In addition, the Meltzer model outcome for hospitalization reflects only those patients who are hospitalized and recover. An additional assumption incorporated into the model is that 70% of fatal cases will occur in hospital. Therefore, a more accurate estimate of hospitalizations is calculated by adding 70% of the fatal cases to the number of patients hospitalized who will recover. The above numbers were calculated using FluAid 2.0 software developed by the U.S. Centers for Disease Control and Prevention (a version of the software can be found online at http://www2a.cdc.gov/od/fluaid/). It utilizes population estimates for 2005 based on 2001 census data. FluAid is designed to provide a range of estimates for the total impact of an influenza pandemic for a given region at a macro level. The program can also provide further detail such as the impact to the health care system and vaccination coverage when additional data and assumptions are entered (e.g., number of hospital beds, morgue capacity, number of patients per day, time to administer one dose of vaccine). The FluAid program differs slightly from the CDC's FluSurge program (http://www.cdc.gov/flu/flusurge.htm), which provides more specific detail with respect to hospital capacity during a pandemic and can display the impact on capacity over time depending on the duration of the pandemic (in weeks). While both FluAid and FluSurge require the user to enter population data for a particular community or area, both programs may yield different results in terms of the estimated number of deaths and hospitalizations for a given population. This may be because both programs use a slightly different age distribution for entry of population data. Please note that these programs were designed to generate estimated figures, and are intended to provide planners with an idea of the potential effect that an influenza pandemic will have on health services within the area so that communities and healthcare facilities can plan appropriately. However, planners should not rely on these programs to provide an accurate prediction of a pandemic impact. The actual impact of a pandemic will depend on a host of factors, including the virulence of the disease, the ease of transmission, the availability and accessibility of antivirals and vaccine, implementation of public health measures and so on. In addition, the assumptions built into both programs are U.S.-based and may not apply equally to Canada. In some cases, these assumptions can be modified within the program to reflect the characteristics of a particular local population. Local planners are encouraged to use either program based on their particular requirements.
• Should an influenza pandemic be severe enough to overwhelm the current Ontario antiviral stockpile, the available supply will be allocated according to national priorities, based on the best available epidemiological evidence (e.g., who is most at risk of complications or death from influenza) , stockpile size and Ontario’s ethical framework for decisionmaking.
• A vaccine will not be available for at least four to six months after the seed strain is identified, which means it will not be available in time for the first wave of illness. Vaccine may be available to mitigate the impact of the second wave.
• A domestic supplier is under contract to provide vaccine for Canada. Vaccines manufactured in other countries are likely to be embargoed during a pandemic.
• In a pandemic caused by a novel virus subtype, the population will not be able to benefit from cross-protection from previous exposure to related strains, and everyone may require two doses of vaccine to induce immunity.
• When vaccine becomes available, Ontario will have to be prepared to administer at least one dose to the entire population within a month.
• Even with a well-matched vaccine, the effectiveness of seasonal influenza vaccine in preventing illness is approximately 70 to 90% in healthy adults (based on experience with annual influenza immunization programs). The impact on the health care system • During a pandemic, the availability of public health and health care workers could be reduced by up to one-third due to illness, concern about disease
Chapter #3: Planning Goals, Approach and Assumptions
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Ontario Health Plan for an Influenza Pandemic August 2008
transmission in the workplace, and family caregiving responsibilities. A shortage of health care providers will result in a decrease in services. For example:
•
During a pandemic, laboratory testing capacity will be reduced due to illness and supply shortages.
•
Hospital capacity is already limited and could be further reduced because of staff illness. Interhospital assistance will be limited because of a rapid spread of influenza. Home care and long-term care homes will provide influenza care that will help avoid hospital admissions and allow early hospital discharges.
•
Non-life-threatening health services and public health programs will be significantly curtailed, consolidated or suspended completely.
• Depending on the severity of the pandemic and the number of health care workers who are infected, redeployment of health care workers across sectors may not be practical. The health care system will have to use a variety of mechanisms to augment/supplement existing health human resources.
• Care protocols may change and standards of practice for “normal” operating conditions may be adapted to meet pandemic/emergency needs.
be declared before the strain of influenza appears in Ontario.
• The overall provincial response during a provincial emergency will be managed from the Provincial Emergency Operations Centre (PEOC), with the Emergency Management Unit providing command and control services for the health care sector and the MOHLTC.
• The Provincial Infectious Diseases Advisory Committee (PIDAC) and the Ministry of Labour will provide ongoing health and safety, clinical, infection control and epidemiological advice to the MOHLTC throughout the pandemic and recovery period.
• Decision-making processes regarding personal protective equipment will include the application of the precautionary principle when there is scientific uncertainty. Communications • A pandemic alert or the start of pandemic activity anywhere in Canada will become a national issue. The Public Health Agency of Canada and the federal government will coordinate interprovincial communications. Provincial health communications strategies must be aligned with the federal communications plan.
• A pandemic will create intense public
• The MOHLTC will provide centralized purchase and distribution of certain personal protective equipment, vaccines/antiviral drugs and other clinical supplies. Managing a pandemic • A provincial emergency will likely be declared early in a pandemic, and could
Chapter #3: Planning Goals, Approach and Assumptions
and media (local, national, international) interest. Ontario will require sophisticated streamlined communications (e.g., live news conferences using latest satellite and fibre optic technologies). Spill over media from other provinces and the United States will affect Ontarians’ perspective, reinforcing the need for a consistent communications approach among jurisdictions.
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Ontario Health Plan for an Influenza Pandemic August 2008
• A pandemic will also create intense pressure on health care workers. Ontario will make use of various communications channels, including websites, electronic mail and fax, to
Chapter #3: Planning Goals, Approach and Assumptions
provide health care workers with information that can be useful for their own protection and for their patients/clients and to help manage broader public anxiety.
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Ontario Health Plan for an Influenza Pandemic August 2008
4. Resources Many of the best scientists in the country met to try to reach a consensus on the cause of the disease or course of therapy ... the conference marked the beginning of a joint federal, state and city effort to prevent recurrence. The Great Influenza, John M. Barry
This chapter lists resources for more information on aspects of planning for an influenza pandemic.
General Information Resources for the Public Ontario Ministry of Health and LongTerm Care Pandemic Planning information web site Available at: www.health.gov.on.ca/pandemic. Telehealth Ontario A free, confidential telephone service you can call to get health advice or general health information from a Registered Nurse. 1-866-797-0000, TTY 1-866-7970007. Ontario Ministry of Health INFOline INFOline would direct callers to the appropriate information source for health information. 1-866-532-3161 (Toll-free in Ontario only), TTY 1-800-387-5559 (toll free in Ontario only); or email
[email protected] . Government of Canada Information on the Preparedness and Response to a Flu Pandemic One-stop access to information from Government of Canada departments and agencies on pandemic, avian and seasonal influenza. Available at: www.pandemicinfluenza.gc.ca . Government of Canada pandemic influenza information hotline For answers to specific questions or comments about avian, seasonal, or pandemic flu. 1-800-454-8302
Chapter #4: Resources
Public Safety Canada Web Site for Pandemic Preparedness A compilation of pandemic preparedness plans from several organizations and levels of government (federal, provincial and municipal plans are linked from this site when available). Available at: www.safecanada.ca/pandemic/ index_e.asp . U.S. Government Avian and Pandemic Flu Information Managed by the U.S Department of Health and Human Services. Available at: www.pandemicflu.gov . World Health Organization Web site for pandemic influenza Planning, technical and surveillance information for pandemic influenza. Available at: www.who.int/csr/disease/influenza/ pandemic/en/. An American Sign Language Video visually presents the contents of the public information brochure. Available at: www.health.gov.on.ca/pandemic . Ten fact sheets for the general public, as well as a public information brochure entitled “What You Should Know about a Flu Pandemic”. All are available in a printable format in 24 different languages. Available at: www.health.gov.on.ca/english/public/ program/emu/pan_flu/ pan_flu_materials.html#fs .
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Ontario Health Plan for an Influenza Pandemic August 2008
Resources for Health Care Providers Ontario Ministry of Health and LongTerm Care Pandemic Influenza Information for Health Care Professionals Information includes provincial emergency status, the Ontario Health Plan for an Influenza Pandemic, fact sheets about treatment and patient care, and links to other health Web sites. Available at: www.health.gov.on.ca/pandemic. MOHLTC Emergency Management Unit Health Care Provider Hotline Includes information for health care providers, employers and first responders. Toll-free phone 1-866-212-2272; email
[email protected] MOHLTC Employers’ Hotline For business organizations with questions relating to emergency planning. Toll-free phone 1-866-212-2272; email
[email protected] Ontario Ministry of Labour (Occupational Health and Safety) Information on Occupational Heath and Safety regulations and protocols in Ontario. Available at: www.labour.gov.on.ca/english/ hs/index.html. Government of Canada Pandemic Influenza Information for Health Care Professionals Provides information kits, technical information and Epidemiological Surveillance reports. Available at: www.influenza.gc.ca/hpi_e.html. Public Safety Canada Website for Pandemic Preparedness A compilation of pandemic preparedness plans from several organizations and levels of government (federal, provincial and municipal plans are linked from this site when available). Available at:
Chapter #4: Resources
www.safecanada.ca/pandemic/ index_e.asp. World Health Organization Website for Pandemic Influenza Planning, technical and surveillance information for pandemic influenza. Available at: www.who.int/csr/disease/influenza/ pandemic/en/. Pandemic Information compiled by the Public Health Agency of Canada (PHAC) Available at: www.phac-aspc.gc.ca/ fluwatch/. Important Health Notices (IHN) Issued by the MOHLTC in response to abnormal events that require ministry direction. The information is intended primarily for use by health care workers and facilities/organizations providing health care, including pharmacies, hospitals, long-term care facilities, community-based health care service providers, and pre-hospital emergency services. IHNs are distributed by email, daily at midnight, and are posted to MOHLTC web site. Available at: www.health.gov.on.ca/english/ providers/program/emu/ihn.htm . Fact sheets for health provider matters regarding protection, treatment, and patient care. Available at: www.health.gov.on.ca/english/ providers/program/emu/pan_flu/ pan_flu_pro_fs.html. Centers for Disease Control and Prevention Information on Community disease control and prevention. Available at: www.hhs.gov/pandemicflu/plan/ pdf/S08.pdf. Canadian Pandemic Influenza Plan Available at: www.phac-aspc.gc.ca/cpip-pclcpi/.
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Ontario Health Plan for an Influenza Pandemic August 2008
World Health Organization Available at: www.who.int/csr/resources/ publications/influenza/ GIP_2005_5Eweb.pdf . Health and Human Services, USA. Pandemic Influenza Plan Available at: www.hhs.gov/pandemicflu/plan/. The Role of Health Leaders in Planning for an Influenza Pandemic A Publication by the Canadian College of Health Service Executives. Available at: www.cchse.org/assets/pandemic/ Pandemic%20English.pdf . Ontario Hospital Association Pandemic Planning Toolkit for Small, Rural, and Northern Hospitals Provides practical strategies, checklists and templates to assist hospitals with the development and implementation of a hospital pandemic plan that would respond to the unique issues and challenges faced in these communities. Available at: www.srnhospitals.com/. Ontario Health Plan for an Influenza Pandemic Personal and Family Care module This interactive training program is designed for health professionals and others who work in health settings. The module provides information and tools to support health workers look after themselves and the people they care about during an influenza pandemic. Available at: www.health.gov.on.ca/english/ providers/program/emu/pan_flu/ pan_flu_care.html.
1.
Context and Assumptions
“Fluwatch” Maintained by the Public Health Agency of Canada (PHAC). Includes archives and
Chapter #4: Resources
up-to-date information on influenza in Canada. Available at: www.phac-aspc.gc.ca/fluwatch/ 05_06/def05-06_e.html . The Meltzer Model. Martin I. Meltzer M.I, Cox N.J, and Keiji Fukuda. The Economic Impact of Pandemic Influenza in the United States: Priorities for Intervention. Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Available at: www.cdc.gov/ncidod/eid/vol5no5/ meltzer.htm . FluAid 2.0 software Developed by the U.S. Centers for Disease Control and Prevention. Available at: www2a.cdc.gov/od/fluaid/. FluSurge program Developed by the U.S Centers for Disease Control and Prevention. Available at: www.cdc.gov/flu/flusurge.htm. FluWorkLoss software developed by the U.S. Centres for Disease Control estimates the potential number of days lost from work due to an influenza pandemic. Available at: www.cdc.gov/flu/tools/fluworkloss/. The Role of Bioethics in an Influenza Pandemic. Gibson J et al (2005). Ethics in a Pandemic Influenza Crisis. Framework for Decision Making. Joint Centre for Bioethics, University of Toronto. WHO Global Pandemic Alert Phases Available at: www.who.int/csr/disease/ avian_influenza/phase/en/
2.
Legislation
The Ontario Health System Improvements Act (2007). Available at: www.ontla.on.ca/web/bills/ bills_detail.do?locale=en&BillID=519 4- 3
Ontario Health Plan for an Influenza Pandemic August 2008
The Ontario Health Protection and Promotion Act (2007). Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_90h07_e.htm.
authorities to share information and manage resources in an outbreak situation. Available at: www.cnphi-rcrsp.ca/cnphi/ index.jsp?src=CPHLN.
The Ontario Crown Employees Collective Bargaining Act (1993). Provides information on the duties of “essential employees” Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_93c38_e.htm .
Ontario Influenza Bulletin Includes regularly updated information on influenza in Ontario. Available at: www.health.gov.on.ca/english/ providers/program/pubhealth/flu/ flu_07/flubul_mn.html.
The Ontario Emergency Management and Civil Protection Act Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_90e09_ev002.htm .
4.
The Ontario Regulated Health Professions Act Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_91r18_e.htm The Ontario Occupational Health and Safety Act Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_90o01_e.htm. The Ontario Workplace Safety and Insurance Act Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_97w16_e.htm.
3.
Surveillance
Public Health Agency of Canada FluWatch surveillance system provides a national picture of influenza activity. www.phac-aspc.gc.ca/fluwatch/ index.html. The Canadian Network for Public Health Intelligence Contains various internet-based applications and resources designed to provide a secure way for public health Chapter #4: Resources
Infection Control
Preventing Respiratory Illnesses, Protecting Patients and Staff Document created by the MOHLTC that includes the FRI Case Finding Protocol (Note: these guidelines have been developed for non-outbreak conditions; however, because influenza is primarily droplet and contact spread, the principles of infection control in the guidelines can be applied more broadly.) Available at: www.health.gov.on.ca/english/ providers/program/infectious/diseases/ ic_fri.html. Infection Prevention A reference booklet for health care workers produced by Engender Health. Available at: www.engenderhealth.org/res/offc/ safety/ip-ref/pdf/ip-ref-eng.pdf . College of Physicians and Surgeons of Ontario – Infection Control in the Physician’s Office. Available at: www.cpso.on.ca/Publications/ infectioncontrolv2.pdf. Ontario Ministry of Labour (Occupational Health and Safety) Information about occupational Heath and Safety regulations and protocols in Ontario as well as a reference about people’s rights as employees. Available at: 4- 4
Ontario Health Plan for an Influenza Pandemic August 2008
www.labour.gov.on.ca/english/ hs/index.html. Infection Control Toolkit Strategies for Pandemics and Disasters. This document can be ordered through the Community and Hospital Infection Control Association by phone at 204-8975990 or 1-866-999-7111 (toll free), or by email at
[email protected]. Canadian Pandemic Influenza Plan Annex F Infection Control and Occupational Health Guidelines during an Influenza Pandemic in Traditional and NonTraditional Health Care Settings. Available at: http://www.phac-aspc.gc.ca/cpippclcpi/pdf-e/15-CPIP-Appendix-FInfection-Control_e.pdf Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. Available at: www.phac-aspc.gc.ca/publicat/ccdrrmtc/99vol25/25s4/index.html. Handwashing Techniques Available at: www.health.gov.on.ca/english/public/ pub/pubhealth/pdf/handwash_tech.pdf. Canada Communicable Disease Report Prevention and Control of Occupational Infections in Health Care. Available at: www.phac-aspc.gc.ca/publicat/ccdrrmtc/02pdf/28s1e.pdf. Canadian Tuberculosis Standards 7th ed. Produced by the Canadian Lung Association in 2000. Available at: www.phac-aspc.gc.ca/tbpclatb/pubs/tbstand07-eng.php Ontario Best Practice Manual Contains information on proper cleaning, disinfection, and sterilization. Available at: Chapter #4: Resources
www.health.gov.on.ca/english/ providers/program/infectious/diseases/ ic_cds.html . Infection Control Guidelines on Handwashing (Health Canada) Available at: www.phac-aspc.gc.ca/publicat/ccdrrmtc/98pdf/cdr24s8e.pdf. Engineering Controls. CSA Standard CAN/CZA-Z317.2-01 Special requirements for heating, ventilation, and air conditioning (HVAC) systems in health care facilities. Toronto: Canadian Standards Association, 2001. A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes (Ministry of Health and LongTerm Care) Available at: www.health.gov.on.ca/english/ providers/pub/pubhealth/ ltc_respoutbreak/ltc_respoutbreak.html.
5.
Occupational Health and Safety
Ontario Ministry of Labour (Occupational Health and Safety) Information about occupational Health and Safety regulations and protocols in Ontario as well as a reference about people’s rights as employees. Available at: www.labour.gov.on.ca/english/hs/ index.html. The Occupational Health and Safety Act Regulation: Health Care and Residential Facilities Available at: www.e-laws.gov.on.ca/html/regs/ english/elaws_regs_930067_e.htm. The Workplace Safety and Insurance Act Available at: www.e-laws.gov.on.ca/html/statutes/ english/elaws_statutes_97w16_e.htm.
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Ontario Health Plan for an Influenza Pandemic August 2008
Ontario Safety Association for Community and Healthcare Pandemic Planning Resources Available at: www.osach.ca/new/SaftInfo/ PanPlan.shtml. For a complete listing of products and services available from all of Ontario's designated Safe Workplace Associations, see: www.preventiondynamics.com/. Canada’s National Centre for Occupational Health and Safety Pandemic Planning Portal. Available at: www.ccohs.ca/pandemic/. United States Department of Health and Human Services Health and Safety Information. Available at: www.pandemicflu.gov/health/ index.html Occupational Health and Safety Association (OSHA) Guidance on Preparing Workplaces for an Influenza Pandemic. Available at: www.osha.gov/Publications/OSHA3327 pandemic.pdf Council of Canadian Academies Report of the Expert Panel on Influenza and Personal Protective Respiratory Equipment Influenza Transmission and the Role of Personal Protective Respiratory Equipment: An Assessment of the Evidence. December 2007. Available at: www.scienceadvice.ca/publications.php. Potential Training Resources for Volunteers
St. John Ambulance Brigade. Brigade Training System (1997). St. John Ambulance Brigade. Handbook on the Administration of Oxygen (1993) ISBN 0-919434-77-0.
Chapter #4: Resources
Yes, You Can Prevent Disease Transmission (1998). The Canadian Red Cross Society.
6.
Immunizations / Vaccines
The Canadian Immunization Guide, 7th Edition A comprehensive guide produced by Health Canada. Available at: www.phac-aspc.gc.ca/publicat/ciggci/index-eng.php Vaccine Storage and Handling Guidelines A set of guidelines produced by Ontario Ministry of Health and Long-Term Care to ensure that vaccines are stored and transported at ideal temperature in the appropriate containers. Available at: www.publichealthontario.ca/portal/ server.pt/gateway/ PTARGS_0_11863_9334_1181_14011_43/ http%3B/ptpublisher.phportal.srv.ehealth ontario.ca%3B7087/publishedcontent/ publish/ssha/pho/communities/ programs/infectious_diseases/vaccine_ storage_guide_janurary_2006_2.pdf . California Department of Health Services Immunization Branch. Information on Comforting Restraining for Immunization. Available at: www.dhs.ca.gov/ps/dcdc/izgroup/ news.htm. Further Information on Safe Vaccine Administration, and Healthcare Worker Safety. Available at: www.who.int/vaccines-documents, www.safety.ed.ac.uk/resources/Bio/ Guidance/General/ Preventing_injuries.shtm, and www.seiu.ca. For additional resources, see the Ontario Emergency Mass Immunization/ Prophylaxis Plan (Chapter 9A).
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7.
Laboratory Services and Safety
The Laboratory Annex, Canadian Pandemic Influenza Plan Contains additional information on avian influenza infection in humans. Available at: www.phac-aspc.gc.ca/cpip-pclcpi/. Transportation of Dangerous Goods Regulations Detailed information on infectious substance (specimen) packaging and transport. Available at: www.tc.gc.ca/tdg/clear/tofc.htm. World Organization for Animal Health (Office International des Epizooties) All novel H5 and H7 influenza strains discovered in a laboratory should also be reported here because of possible “crossspecies” transmission and infection. Available at: www.oie.int/eng/oie/en_oie.htm. Public Health Agency of Canada Containment Levels Updated information is available from the Office of Laboratory Security of the PHAC. (Phone) 613-957-1779, or (fax) 613941-0596 or available at: www.phac-aspc.gc.ca/ols-bsl/index.html.
Chapter #4: Resources
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5. Surveillance: Detecting and Monitoring Influenza Investigators and public health officials are not simply sitting back waiting for the next pandemic. In 1948 the World Health Organization established a formal monitoring system for influenza viruses. Currently 110 laboratories in 82 countries participate. … The surveillance has two purposes: first, to track mutations of existing viruses to adjust each year’s vaccine, and second, to search for any sign of the emergence of a new strain – a strain that might cause another pandemic. The Great Influenza, John M. Barry
hospitalizations, and case fatality rate
Under the Health Protection and Promotion Act, the public health system is responsible for: protecting public health, and preventing, managing, and controlling the spread of communicable diseases, including influenza. Surveillance is the continuous and systematic process of collecting, analyzing, interpreting and disseminating descriptive information to monitor public health and ensure timely interventions to reduce morbidity and mortality.
5.1 Objectives of Pandemic Surveillance 1.
To detect the pandemic strain early in Ontario.
2.
To track the occurrence, severity, and progression of the pandemic, based on the WHO pandemic phases.
3.
To monitor influenza-like illness (ILI) activity in order to: •
detect unusual events (new strains including epizootic strains, antigenic drift/shift, unusual outcomes/syndromes, unusual severity, unusual distribution)
•
compare new strains with vaccine composition and recommendations
•
estimate the impact of ILI in terms of attack rate, outpatient visits,
Chapter #5: Surveillance
•
4.
describe the affected population/s in order to identify high risk groups, modes of transmission, and risk and protective factors. To share surveillance information with responders to help identify disease; guide prevention, control, and research; and evaluate treatment, prophylaxis and education.
5.2 Elements of a Comprehensive Surveillance Program Ontario must have the capacity to help the Public Health Agency of Canada (PHAC) identify and/or monitor new strains of influenza quickly and track virus activity. Prompt identification of the viral strain increases the lead time management measures. Surveillance is the means by which Ontario will track the epidemiology and impact of influenza. Ontario’s surveillance program attempts to balance the need for information with the capacity of stakeholders to collect and submit information. Comprehensive surveillance for influenza includes:
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Ontario Health Plan for an Influenza Pandemic August 2008
•
Laboratory / virology surveillance (i.e., isolating/ analyzing influenza viruses, diagnosing influenza) to monitor the antigenic drift and shift of circulating influenza viruses as well as other respiratory pathogens. Because the signs and symptoms of influenza are similar to those of other respiratory pathogens, laboratory testing is critical to identify novel influenza strains. Testing may be used to identify influenza in the early stages of a pandemic. Antiviral susceptibility monitoring is conducted to evaluate sensitivity and resistance in circulating influenza strains.
•
Disease / epidemiologic surveillance (i.e., monitoring of disease activity levels by sentinel physicians, subpopulations at risk, hospitalization rates, case fatality rates) to determine the extent and severity of influenza pandemics in relation to baseline levels of ILI and to guide prevention and management strategies (e.g., setting priorities for the use of limited antiviral/vaccine supplies).
•
Animal health surveillance to detect respiratory outbreaks in domestic and wild animals, particularly in swine, poultry and other fowl. These epizootics may pose risks to human health.
•
Vaccine and antiviral uptake surveillance to monitor, evaluate, and (if necessary) reallocate vaccine or antiviral stocks, and modify guidelines for their use.
•
Adverse event surveillance to detect unusual adverse events related to vaccine and antiviral use.
•
Data collection systems that provide an efficient, timely way to collect information. The integrated Public
Chapter #5: Surveillance
Health Information System (iPHIS) for public health reporting and surveillance in Ontario will play a major role especially in the interpandemic and pandemic alert phases. iPHIS can help identify the unique characteristics of new and emerging infectious diseases and be quickly configured to assist decisionmakers and inform control measures while ensuring a consistent approach to data gathering. During the pandemic, when illness is expected to be widespread, hospital emergency departments, flu centres and Telehealth will be key data sources. Because of the array of data to be collected (e.g., vaccine and antiviral uptake) and the range of health care sites providing surveillance data to health units during the pandemic phase, a variety of data collection systems may be used in addition to iPHIS, such as a web-based surveillance system that can be used to collect aggregate data on ILI activity. •
Analysis of surveillance data to provide information that will be used to guide and trigger pandemic plans.
•
Effective lines of communication at the local, provincial, federal, and global levels. Lines of communication must be defined in advance, and they must be robust (i.e., viable during power outages).
Information generated through this type of integrated surveillance program will be used to: determine when a pandemic begins; track its course locally, provincially, nationally and globally; guide vaccine and antiviral use, and evaluate management efforts. Ontario’s influenza surveillance system is
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Ontario Health Plan for an Influenza Pandemic August 2008
built on the existing systems for communicable disease control. All the elements currently in place support surveillance during the interpandemic and pandemic alert periods (i.e., preparedness stage). During the pandemic period, the province’s surveillance objectives may change, and more work must be done to ensure the existing system can adapt and will be useful during the response stage.
5.3 Surveillance Communications Effective influenza surveillance is based on close collaboration and communication among local/regional, provincial/ territorial, federal and international health authorities. iPHIS will support timely reporting of data from public health units to the MOHLTC, and from the MOHLTC to PHAC, and from the MOHLTC back to public health units and health care providers.
submit reports electronically, which can inform national and international surveillance efforts during a pandemic Surveillance Data Reporting Cycle Figure 5.1 illustrates the proposed timing of reporting on pandemic activity. During a pandemic, hospitals, long-term care homes and influenza assessment and referral centres (when required) will submit daily data on influenza visits/cases and deaths (as of 24:00 each day) by 10 am the following day using a web-based surveillance system. (MOHLTC will provide detailed instructions for web reporting when a pandemic is declared.) MOHLTC will then provide daily information about the severity and distribution of the pandemic based on this and other surveillance information (e.g., lab, Telehealth, and sentinel physician reports). This information will be discussed at the public health teleconference at 13:00 each day, and used to inform the public and to develop the Important Health Notices that will be issued at midnight.
The ministry is developing a web-based surveillance system that will be used to Figure 5.1: Pandemic Surveillance Reporting Clock
Chapter #5: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008
5.4 Surveillance Activities During the Interpandemic and Pandemic Alert Periods Figure 5.2 illustrates the routine influenza surveillance activities that Ontario currently has in place, and will maintain throughout the Interpandemic and Pandemic Alert Periods (i.e., preparedness stage of emergency management).
5.5 Surveillance During the Pandemic Period During a pandemic, Ontario’s response will be based on local “triggers” which may or may not correspond to the global situation (i.e., the level of pandemic activity in Ontario may be different from pandemic activity in other parts of the world or even other parts of Canada). For example, there may be a time in Phase 6 (large clusters but spread still localized) where Canada experiences an outbreak in a few discrete locations as opposed to a nation-wide outbreak. Health and emergency services planners at both the provincial and local levels will have to confirm the level of pandemic activity in their jurisdiction in order to respond appropriately.
Chapter #5: Surveillance
During phase 6, Ontario will likely reduce or curtail some surveillance activities, so resources can be devoted to enhancing or adding activities that will help understand the nature of the virus and its spread, and the impact of antivirals and vaccine. Figure 5.3 illustrates the surveillance activities that will be undertaken during the pandemic period, including new activities that will be added and current activities that may be reduced or curtailed, depending on resources. Figure 5.4 is a summary of surveillance activities by pandemic phase, and illustrates the trigger points when surveillance activities will be initiated or changed.
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 5.2: Surveillance Activities During the Interpandemic and Pandemic Alert Periods
See page 5.7 for notes to Figure 5.2.
Chapter #5: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 5.3: Proposed Surveillance Activities During the Pandemic Period
Chapter #5: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008 Notes to Figure 5.2 and 5.3. 1. The goal of the FluWatch program is to have 1 sentinel physician per 250,000 population recruited from across the country’s census divisions. Based on the 2001 census, Ontario has 1 physician per 165,000 people. 2. Influenza activity is reported in one of four categories: no activity, sporadic activity (i.e., sporadically occurring ILI or laboratory-confirmed influenza with no outbreaks detected), localized activity (i.e., outbreaks affecting a single geographic area within the health unit jurisdiction, such as an outbreak in one nursing home), or widespread activity. 3. Ontario has designated a number of laboratories to conduct influenza surveillance including the following public health laboratories – Central (Etobicoke), Kingston, Timmins, Windsor, Thunder Bay, Sault Ste. Marie, Orillia and Sudbury – and the following hospital-based laboratories – the Children's Hospital of Eastern Ontario (Ottawa), the Hospital for Sick Children (Toronto), Toronto Medical Laboratories, Hamilton Health Science Centre, St Joseph's Hospital (London) and Sunnybrook and Woman’s Health Sciences Centre (Toronto). Other Ontario laboratories participate in influenza surveillance activities, but they do not take part in the FluWatch Program. Note: In addition to these sources of surveillance information, some health units collect information on respiratory infections in schools, day-care centres and workplaces.
Figure 5.4: Surveillance Activities by Pandemic Phase
Chapter #5: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008
5.6 Next Steps The surveillance priorities will be to: •
increase the number and geographic distribution of sentinel physicians
•
consider the feasibility of collecting data from detention centres
•
further develop a web-based surveillance system to allow institutions and flu centres to submit aggregate information electronically to the ministry
•
explore how information on influenzarelated mortality during a pandemic can be collected and sent to public health units so they can determine the severity of the pandemic and the appropriate intensity of public health measures
•
identify trigger points for the activation of a web-based surveillance system.
Chapter #5: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008
5A. Surveillance Tools Both Ontario and the Public Health Agency of Canada have developed a number of tools and resources to assist with influenza surveillance (see Chapter 4: Resources).
Contents Preliminary/Weekly Institutional Respiratory Infection Outbreak Form*........................................1 Final Institutional Respiratory Infection Outbreak Form*....................................................................2 Surveillance Activities by Level and by Pandemic Period and Phase ................................................4
*The forms are for use by hospitals operating under the Public Hospitals Act, private hospitals, long-term care homes, and retirement homes with more then 10 beds, children’s residences and all facilities operating under the Developmental Service Act
Ontario Health Plan for an Influenza Pandemic August 2008
Preliminary/Weekly Institutional Respiratory Infection Outbreak Form To track the occurrence, severity and progression of the pandemic, surveillance data for institutional respiratory infection outbreaks during the pandemic are to be reported by each institution using the web-based surveillance system. This information is usually collected by the institution’s infection prevention and control practitioner or designate. Long-term care homes, hospitals and retirement homes with more than 10 beds: please submit preliminary and updated reports through the Ministry of Health and Long-Term Care’s web-based surveillance system within 24 hours of an outbreak being declared. Institution Information For updates, reporting time period covered: ((yyyy/mm/dd) to (yyyy/mm/dd):
Institution Master #:
Outbreak #:
Institution Name: Institution Address:
Name of person completing report:
City/Town of Institution:
Contact Phone #:
Postal Code of Institution:
Date Outbreak Reported to Health Unit (yyyy/mm/dd):
Date of onset of illness in first case
(yyyy/mm/dd):
Institution Type Long-Term Care Home
Hospital:Operates under Public Hospitals Act?
Retirement Homes
Type:
Acute
Outbreak Description
Psychiatric
Yes
No Rehab
Immunization Information
Residents or Patients
Staff *
New Cases▲
New Cases▲
Cumulative Number§
Chronic
Cumulative Number§
Total # cases
Residents or Patients
Staff *
New Cases▲
New Cases▲
Cumulative Number§
Cumulative Number§
# cases immunized prior to outbreak
# deaths among cases attributed to outbreak Residents or Patients
Staff*
Of cases who died, # immunized prior to outbreak
Total # in institution
Laboratory Data Lab Confirmation:
□ Yes (check causative organism/s)
□ Pending
□ Specimens NOT submitted
□ No. of lab-confirmed cases
Influenza A
Influenza B
RSV
Rhinovirus
Parainfluenza
Adenovirus
Enterovirus
Other (specify)______________________________
* Staff: All persons who carry on activities in the facility including employees, nurses, students, medical house staff, physicians, contract workers and volunteers. ▲ Initial Report: indicate the total number of cases ▲ Update: indicate the number of new cases since last update § Update/s: indicate the cumulative number of cases. § For initial reports enter as N/A Prior to outbreak: Immunized with two doses of the pandemic vaccine at least 2 weeks before the onset of the outbreak
Chapter #5A: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008
Final Institutional Respiratory Infection Outbreak Form Long-term care homes, hospitals and retirement homes with more than 10 beds: please submit final reports through the Ministry of Health and Long-Term Care’s web-based surveillance system within three weeks of an outbreak being declared over. Health Unit Information
Institution Information
Outbreak #:
Institution Master #:
Name of individual completing report:
Institution Name:
Contact Phone #:
Institution Address:
Date Outbreak Reported to Health Unit (yyyy/mm/dd):
City/Town of Institution:
Date Outbreak Declared Over (yyyy/mm/dd):
Postal Code of Institution:
Date form submitted (yyyy/mm/dd):
Date of onset of illness in first case (yyyy/mm/dd): Institution Type
❏
Long-term Care Home
Hospital operates under Public Hospitals Act?
❏
Retirement Home (with more than 10 residents)
Type:
❏
Outbreak Description
❏
Acute
Chronic
❏ ❏
Yes
Psych
❏
❏
No
Rehab
Immunization Information Staff*
Residents or Patients
Residents or Patients
Total # in institution
Staff*
# of cases immunized prior to outbreak
Total # of cases # of deaths among cases attributed to outbreak
Of cases who died, # immunized prior to outbreak
# of cases including cases who died who were vaccinated (when pandemic vaccine available)
Laboratory Data Lab Confirmation:
❏
Yes (check causative organism/s)
❏
No (no organism/s identified)
❏
Specimens NOT submitted
# of lab confirmed cases: __________
❏ ❏
Influenza A
❏ ❏
Influenza B
Rhinovirus
❏
Enterovirus
❏
Other (specify):
Parainfluenza
❏ ❏
RSV Adenovirus
*Staff: All persons who carry on activities in the facility including employees, nurses, students, medical house staff, physicians, contract workers and volunteers.
Prior to outbreak Immunized with two doses of the pandemic vaccine at least 2 weeks before the onset of the outbreak
Chapter #5A: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008
Antiviral Use Were antivirals used during the outbreak?
Yes No
If an antiviral medication was prescribed during the outbreak, please complete the chart below: Residents/Patients Antiviral Used
Oseltamivir
Other (Please specify):
Staff Oseltamivir
Other (Please specify):
Total # of individuals who received EITHER a treatment OR a prophylactic dose of antiviral medication # of individuals who received a dose of antiviral medication who developed severe side effects (if applicable)
Please describe any side effects that were severe enough to discontinue antiviral medication:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________________
Chapter #5A: Surveillance
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Ontario Health Plan for an Influenza Pandemic August 2008 Surveillance Activities by Level by Pandemic Period and Phase Federal Level
Provincial Level
Review and confirm that all national interpandemic surveillance activities (via FluWatch) are operational Work with P/Ts to develop communication strategy for epidemiological data to be collected during pandemic alert and pandemic phases
Confirm that: all interpandemic surveillance activities (i.e., laboratory surveillance; influenza activity reporting; reports of lab-confirmed influenza cases; respiratory infection outbreaks in institutions) are operational
Continue with all Phase 1 activities Alert those currently involved in influenza surveillance (e.g., PIC, CCMOH, CPHLN, FluWatch, local HUs) and advise them to remain on alert for further updates
Continue with all Phase 1 activities Disseminate alerts
Continue with all Phase 1 activities Disseminate alerts
Continue with all Phase 2 activities Disseminate regular updates via e-mail, fax, teleconferencing and web postings as necessary Share surveillance information in a timely manner with provincial and local health authorities and the general public Identify special study needs, develop and disseminate protocols for special studies Report information to WHO as required in regards to human cases of novel influenza, if cases identified in Canada Develop and disseminate additional data elements to be collected from novel influenza cases (e.g., exposure information)
Continue with all Phase 2 activities Disseminate PHAC information, including provincial-specific information. Confirm that surveillance tools required for later phases (e.g., information for institutional respiratory infection outbreaks) are available and up-to-date Report information as needed in regards to human cases of novel influenza, if identified Identify special study needs Disseminate protocols for special studies Identify surveillance/ information needs should pandemic progress to next phase Develop and disseminate additional data elements to be collected from novel influenza cases (eg., exposure information)
Continue with all Phase 2 activities Share surveillance information with stakeholders Maintain vigilance in FRI screening. Implement FRI with travel history screening, since human infection with novel influenza virus has occurred.. FRI screening facilitates detect ion of novel influenza cases in Ontario Investigate and report additional data elements (e.g. exposure information) should cases infected with novel influenza be identified in Ontario
Continue with all Phase 3 activities Monitor evolving situation, identify additional needs for
Continue with all Phase 3 activities Disseminate alerts about the pandemic alert phase to increase
Continue with all Phase 3 activities Disseminate alerts about the progress of the pandemic to
WHO Pandemic/ Phase Interpandemic Period: Phase 1 No new influenza virus subtypes have been detected in humans
Interpandemic Period: Phase 2 A circulating animal influenza virus subtype poses a substantial risk of human disease Pandemic Alert Period: Phase 3 Human infection(s) with a new subtype, but no humanto-human spread or spread to a close contact only
Pandemic Alert Period: Phase 4 Small cluster(s)
Chapter #5A: Surveillance
Ensure surveillance data is being collected and forwarded to appropriate authorities Work with PHAC to develop communication strategy for epidemiological data to be collected during pandemic alert and pandemic phases Communicate surveillance information through the Ontario Influenza Bulletin Maintain vigilance in FRI screening
Local Level Maintain all interpandemic surveillance activities Maintain vigilance in FRI screening Liaise with hospitals and longterm care homes on FRI screening Use iPHIS for electronic transmission of individual level and institutional respiratory infection outbreak reports Ensure surveillance data is being collected and forwarded to MOHLTC
Confirm that surveillance tools required for later phases (e.g., information for institutional respiratory infection outbreaks) are available and up-to-date Identify surveillance/ information needs for next phase
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Ontario Health Plan for an Influenza Pandemic August 2008 WHO Pandemic/ Phase
Federal Level
with limited human-tohuman transmission but spread is highly localized, suggesting that the virus is not well adapted to humans
enhanced surveillance information should pandemic progress to next phase Provide alerts about the pandemic alert phase to increase awareness and inform public health and clinical decision making Review if new or updated surveillance tools are needed
awareness and inform public health and clinical decision making Review if new or updated FRI surveillance tools are needed. Disseminate updated surveillance tools if developed
increase awareness and inform public health and clinical decision making Implement any new/updated FRI/SRI surveillance tools
Phase 5
Continue with all Phase 4 activities Review/update case definitions
Continue with all Phase 4 activities Implement:
Review/revise information required for surveillance purposes for a potential progression to Phase 6 (pandemic) Implement border-based surveillance (depending on origin of cases), including notifications to ill and well travelers Confirm the information to be collected on cases and screening measures and how this will be done (e.g., database issues, data flow)
• any new/updated case definitions • any new/updated FRI surveillance tools (especially for areas known to receive a lot of travelers from affected areas)
Continue with all Phase 4 activities Implement any new/updated FRI/SRI surveillance tools (especially for areas known to receive a lot of travelers from affected areas) Review/revise information required for surveillance purposes for potential progression to Phase 6 (pandemic)
Continue with all Phase 5 activities until no longer sustainable Evaluate current epidemiology of pandemic to direct resources to high risk groups Define clinical spectrum of disease (based on feedback from local level experts), and revise case definitions as necessary Monitor surveillance activities; compile and report outcomes Review protocols for special studies and establish dedicated teams to activate the studies in collaboration with other public health authorities
Continue with all Phase 5 activities until no longer sustainable Evaluate current epidemiology of pandemic to direct resources to high risk groups Adopt and implement revised case definitions as necessary
Larger cluster(s) but human-tohuman spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible
Pandemic Period: Phase 6 Increased and sustained transmission in general population
Monitor antiviral effectiveness, safety and resistance
Pandemic Period: Phase 6 cont. Regional and multi-regional epidemics
Continually review/revise surveillance case definitions as necessary Provide epidemiological summaries to characterize outbreaks and impacts
Chapter #5A: Surveillance
Provincial Level
Activate web-based data collection system, as needed Review/revise information required for surveillance purposes for a potential progression to Phase 6 (pandemic)
Monitor surveillance activities and compile and report outcomes Continue with enhanced surveillance until no longer sustainable
Local Level
Continue with all Phase 5 activities until no longer sustainable Maintain FRI with travel history screening to detect entry of cases infected with pandemic strain Evaluate current epidemiology of pandemic to direct priorities to high risk groups Adopt and implement revised case definitions as necessary Provide timely data, and report to province
Activate web-based data collection system, if not done during 5.2 (streamlined surveillance) Monitor antiviral uptake, effectiveness, safety and resistance Review protocols for special studies and assist with establishment of dedicated teams to activate the studies in collaboration with other public health authorities Disseminate pandemic alerts
Participate in special studies and assist with establishment dedicated teams to activate the studies in collaboration with other public health authorities Continue with enhanced surveillance until no longer sustainable Disseminate pandemic alerts
Adopt surveillance case definitions as necessary Disseminate epidemiological summaries to characterize outbreaks and impacts Monitor surveillance activities;
Modify definitions, activities, processes and tools as required based on direction from the province Disseminate epidemiological summaries to characterize
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Ontario Health Plan for an Influenza Pandemic August 2008 Federal Level
Provincial Level
Local Level
Monitor surveillance activities; compile and report outcomes Monitor and report on progress of special studies Continually monitor data collection, transmission procedures in an attempt to streamline procedures to optimize efficiency and timeliness of data reporting Maintain ongoing surveillance to detect second or later waves early Monitor vaccine effectiveness, adverse reactions and coverage, once vaccine available
compile and report outcomes Monitor and modify (if necessary) data collection/transmission processes/protocols Monitor and report on progress of special studies Maintain ongoing surveillance to detect second or later waves early Monitor vaccine effectiveness, adverse reactions and coverage, once vaccine available
outbreaks and impacts Continue to provide timely data and analysis
Estimate burden of disease during pandemic period (e.g., through special studies), provide epidemiological summaries to characterize the impact of pandemic waves in Canada Review/modify case definition, evaluate the current epidemiology and decreasing levels of activity in Canada Determine ongoing surveillance required to document the end of the first wave and detect any new cases/outbreaks
Estimate burden of disease in the province during pandemic period and develop epidemiological summaries to describe the impact of pandemic waves in Ontario Review/adopt case definition; evaluate the current epidemiology and decreasing levels of activity in Ontario. Determine ongoing surveillance needs for both documentation of end of first wave and detection of any new cases/outbreaks
Work with MOHLTC to estimate burden of disease during pandemic period and develop epidemiological summaries to describe the impact of pandemic waves in local jurisdiction Scale down streamlined surveillance as appropriate and resume inter-pandemic response Review/adopt case definition, evaluate the current epidemiology and decreasing levels of activity in local jurisdiction
Collect information required to evaluate surveillance activities
Collect information required to evaluate surveillance activities
Collect information required to evaluate surveillance activities
Evaluate pandemic surveillance system performance and plan Resume seasonal influenza laboratory and disease surveillance activities and communicate via FluWatch improvements as required
Evaluate pandemic surveillance system performance and plan improvements as required Resume seasonal influenza laboratory and disease surveillance activities and communicate via Ontario Influenza Bulletin
Evaluate pandemic surveillance system performance and plan improvements as required Resume seasonal influenza surveillance activities
WHO Pandemic/ Phase
Pandemic Period: Phase 6 cont. Pandemic Subsiding
Postpandemic Period Return to Interpandemic phase
Chapter #5A: Surveillance
Maintain ongoing surveillance to detect second or later waves early Monitor vaccine effectiveness, adverse reactions and coverage, once vaccine available Hospitals, long-term care homes and retirement homes with more than 10 beds report aggregate respiratory infection outbreak information using ministry’s web-based surveillance system
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Ontario Health Plan for an Influenza Pandemic August 2008
6. Public Health Measures Nothing could have stopped the sweep of influenza through … the world – but ruthless intervention … might have interrupted its progress and created occasional firebreaks. Actions as ruthless as those taken in 2003 to contain the outbreak of SARS could well have had effect. Influenza could not have been contained as SARS was – influenza is far more contagious. But any interruption in influenza’s spread could have had significant impact. For the virus was growing weaker over time. Simply delaying its arrival in a community or slowing its spread once there – just such minor successes – would have saved many, many thousands of lives. The Great Influenza, John M. Barry
Public health measures are non-medical interventions used during a pandemic to reduce the spread of disease that include but are not limited to:
• providing public education • issuing travel restrictions and screening travellers
• conducting case and contact management
• social distancing measures, such as restricting public gatherings and closing schools. The key questions in planning for the use of public health measures during a pandemic are: 1.
Which measures should we use (i.e., which will be most effective)?
2.
When should we use them (i.e., what is the trigger to initiate a measure) and for how long (i.e., duration)?
3.
What are the risks (i.e., what social impact will they have beyond their effect on the pandemic, such as a negative effect on essential services or the economy) and are there ways to reduce or mitigate those risks?
Chapter #6: Public Health Measures
6.1 Objectives • To decrease the number of individuals exposed to the novel virus and potentially slow the progress of the pandemic
• To slow disease spread and gain time for implementing medical measures (e.g., vaccine)
• To reduce the morbidity and mortality caused by the pandemic.
6.2 Authority to Use/Enforce Public Health Measures Under the Health Protection and Promotion Act, the local medical officer of health has the authority to implement public health measures within his or her health unit area, such as issuing communicable disease orders and restricting gatherings. Under the Immunization of School Pupils Act, the local medical officer of health also has the authority to issue orders respecting students in a school. (For more information on legislation, see Chapter 2.) In the event of an influenza pandemic, the threat will not be limited to a single health unit so the decision to use particular public health measures will be made by the Chief Medical Officer of Health in consultation with local medical officers of health and others. Close collaboration among health units on the type, timing and duration of 6-1
Ontario Health Plan for an Influenza Pandemic August 2008
public health measures will help ensure a consistent approach across the province and enhance both public confidence and the public’s adherence to public health measures.
6.3 Definitions, Activities and Timeframes Table 6.1 defines six public health measures that may be used in Ontario to slow the spread of pandemic influenza. It also
describes the types of activities that can be used to implement each measure. The ✓ before an activity indicates that it is already in place: the ✍ before an activity indicates that it is in development. The third column gives the timeframe for the measure: when it would be initiated and how long it would be maintained.
Table 6.1: Definitions of Public Health Measures Public Health Measure and Definition
Types of Activities Used to Implement the Measure
Timeframes When? For how long?
1. Public Education
Public education includes providing information about influenza and how it spreads, as well as information about:
Public education should begin as early as possible in the pandemic (i.e., in the pandemic alert period) and continue throughout a pandemic.
Clear, consistent, accurate information given to the public to help them be prepared for a pandemic and reduce their risk.
✓ i. Individual infection prevention and control measures, including education about: • hand hygiene, respiratory/cough etiquette, including covering one’s mouth when coughing or sneezing and proper tissue disposal, and other personal protective measures to avoid droplet/contact spread • the importance of fresh air and how to increase air circulation in buildings • the wearing of masks by the public or people who do not have influenza. This practice is not recommended at this time because it has not been proven effective in stopping or slowing the spread of influenza; however if individuals choose to wear masks, they should: • wear a surgical mask • learn the proper procedures for putting masks on and taking them off (to avoid contact with droplets) • know how to dispose of the mask properly (i.e., without increasing the risk of infection) • know that a mask or any other personal protective equipment is not a substitute for hand hygiene • how to clean and disinfect environmental surfaces to avoid droplet/contact spread. ✓ ii. Social distancing, including messages advising people: • to stay home from day-care, school, work and public events if they have influenza-like-illness (ILI) symptoms or have had contact with someone with ILI • to avoid large gatherings or crowds • to reduce non-essential travel • when and how to get information on any closures, cancellations or changes to community services/events • about emergency preparedness supplies they should have in their homes (e.g., food, water)
✍
iii. Influenza care, including information about:
• how to access health care advice/triage services (e.g., Telehealth, internet sites) • where and how to seek medical care in a way that minimizes exposure to influenza (e.g., go to your family physician for other health services, go to flu centres if you have influenza symptoms) • self care and how to care for others who are ill at home.
Chapter #6: Public Health Measures
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Ontario Health Plan for an Influenza Pandemic August 2008
Public Health Measure and Definition
Types of Activities Used to Implement the Measure
Timeframes When? For how long?
2. Travel Restrictions
✓ i. Foreign travel advisories
Restricting people from traveling between countries in order to slow the spread of influenza. Note: Travel restrictions are the responsibility of the Public Health Agency of Canada (PHAC), and Ontario will comply with federal directions.
The PHAC website (http://www.phac-aspc.gc.ca) provides Travel Health Advisories about the occurrence of communicable diseases around the world and recommends measures to reduce risk. For example, on June 1, 2007, the website advised travelers going to any of 13 countries that have had confirmed cases of H5N1 (avian influenza) to avoid contact with domestic poultry and wild birds, to ensure all poultry dishes are thoroughly cooked and to practice proper hand hygiene.
Depending on the severity of the pandemic strain, restrictions on foreign travel could begin very early in a pandemic in an effort to keep the pandemic strain out of Canada, and could continue throughout the pandemic.
✍
ii. Voluntary foreign travel restrictions
In the event of a pandemic, PHAC could either ask people to consider deferring unnecessary travel or recommend that people defer unnecessary travel (depending on the severity of pandemic).
✍
iii. Closing borders
During a pandemic, PHAC could close the borders, restricting people who have symptoms of ILI, have had contact with someone who has ILI or who is from an area where there is pandemic activity from entering the country.
✍
iv. Reducing transit use
During a severe pandemic, public health officials could recommend strategies to reduce the number of people traveling by transit at one time (i.e., staggering work hours, controlling the number of individuals permitted on streetcars and subway cars). 3. Case Management Case management involves public health nurses and inspectors OR public health staff following up with individuals ill with influenza (i.e., cases) to provide information and strategies to reduce transmission to other people.
✍
i. Voluntary isolation
Cases (i.e., people with ILI) are asked to isolate themselves and avoid contact with others, usually for up to 5 days after symptoms develop (7 days for children, who are infectious longer) – although the time will be determined by the epidemiology of the pandemic strain. While isolated, the person should practice good hand hygiene and cough etiquette (i.e., frequent, thorough hand hygiene; cover their mouth when coughing or sneezing); stay two metres* away from others (i.e. social distancing); and wear a surgical mask when out in public. People with influenza could be isolated at home or in a hospital, depending on the severity of their illness and hospital capacity.
✍
ii. Self Care
Cases (people with ILI) and their families are given clear, concise information about: • how to care for someone with influenza at home • when and where to seek medical attention.
✍
iii. Antivirals
Public health nurses and inspectors OR public health staff ensure that people with pandemic influenza/symptoms receive antivirals (from the provincial stockpile for treatment), know how to take them, and adhere to treatment.
✍
Because case management is highly labour intensive, public health units will likely only be able to use the traditional individiual or one-to-one approach in the pandemic alert period and early in the pandemic period, when there are a relatively small number of cases and there is an opportunity to contain the virus. The main purpose will be to confirm the presence of the pandemic strain. After that time, public health units may use a group/public education approach to reinforce the importance of isolation, self-care, and compliance with treatment.
iv. Public health follow-up
Case management could also include: • Individual monitoring of people with ILI (e.g., daily phone calls, visits) to ensure they are complying with voluntary isolation, care and treatment, gathering information on their contacts, and notifying the contacts • Group education by providing ongoing public information and messages for people in voluntary isolation
Chapter #6: Public Health Measures
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Ontario Health Plan for an Influenza Pandemic August 2008
Public Health Measure and Definition
Types of Activities Used to Implement the Measure
Timeframes When? For how long?
4. Contact Management
✓ i. Education
Contact management is a highly labour intensive process of individually contacting anyone who has had close contact (i.e., within two metres*) with someone with influenza during the time the person was infectious. Contacts are notified and advised to take steps to protect their health and the health of others.
Public health nurses and inspectors OR public health staff advise contacts about symptoms to watch for and what to do if they become ill.
Because contact management is highly labour intensive, public health units will likely only be able to provide individual contact management in the pandemic alert period and early in the pandemic period, when there are a relatively small number of cases and there is an opportunity to contain the virus. The main purpose will be to confirm the spread of the pandemic strain. After that time, public health units will rely more on public education messages to reinforce the importance of being aware of symptoms, seeking care, and voluntary or modified quarantine for people who have been exposed to someone with influenza.
✍
ii. Voluntary and modified quarantine
Depending on the severity of the virus, close contacts of cases (people with ILI) who are otherwise healthy may be asked to quarantine themselves at home and avoid contact with other people until the incubation period is over (usually three days but time will be determined based on the pandemic strain). People who are symptom-free may be asked to maintain a modified quarantine, that is: they can leave the home to obtain essential supplies (e.g., food for the family) but not to go to work or engage in social activities. This type of modified quarantine allows families to continue to function, while reducing the risk of exposing others.
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ii. Public health follow-up
Follow-up with contacts can occur in two ways: • Individual monitoring of contacts to ensure they are complying with voluntary quarantine, noting if they develop symptoms (i.e., become cases), directing them to care if they develop symptoms and notifying their contacts • Group education by providing ongoing public information and messages to people in voluntary modified quarantine.
5. School and day-care based infection prevention and control and social distancing measures School and day-care-based measures are steps designed to reduce the number of contacts that children have in schools and day care centres. They are important because schools are dense social environments and children without preexisting immunity to influenza viruses are more susceptible than adults to infection. Children also shed more virus for a longer period of time, which makes them more infectious, and they are less likely to practice hand hygiene. Compared to adults, children are responsible for more secondary household transmission (CDC, 2007).
✓ i. Infection prevention and control measures Everyone in school and daycare settings are encouraged to adopt infection prevention and control measures including: • washing hands frequently and meticulously • practicing respiratory hygiene/cough etiquette, including covering one’s mouth when coughing or sneezing and proper tissue disposal • cleaning and disinfecting environmental surfaces (e.g. door handles, lunchroom tables, desks, etc.) • increasing fresh air in buildings (i.e., open windows) • asking parents to keep children who are sick at home.
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ii. Social Distancing
Public health can request changes in the school environment or school practices that reduce contacts between children by limiting the number of children in a given area and keeping children further apart, such as: • space students 2 metres* (6 ft) apart • suspending interschool sports activities • avoiding social mixing of different groups of children (e.g., school dances) • reducing large gatherings within the school setting (e.g., cancelling assemblies, having students eat lunch in class rooms, staggering recesses or lunches if possible, cancelling school trips) • reducing the number of children allowed in a given area at a given time • suspending non-essential after school activities (e.g., clubs, sports).
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Infection prevention and control and social distancing measures in schools and daycares would be implemented early in the pandemic and be maintained throughout a pandemic. School closures, if required, would also have to be implemented early in a pandemic to be effective (see below), and would be maintained for between four and 12 weeks, depending on the severity of the pandemic.
iii. School/Day Care Closures
The public health unit can issue orders to temporarily close day cares, elementary schools and high schools. Any decision to close schools would be discussed with the affected school boards.
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Public Health Measure and Definition
Types of Activities Used to Implement the Measure
Timeframes When? For how long?
6. Social distancing in the community Social distancing measures are designed to reduce the number of close contact encounters that adults have in the community – including the workplace and the post secondary education system.
✓ i. Workplace infection prevention and control for nonhealth care settings Public health provides information and education that helps non-health care workplaces implement infection prevention and control measures including: • installing hand sanitizer stations in all workplaces and post secondary institutions • encouraging employees to wash their hands frequently and meticulously and practise respiratory hygiene/cough etiquette, including covering their mouth when coughing or sneezing and proper tissue disposal • cleaning and disinfecting environmental surfaces • increasing fresh air in buildings (i.e., open windows) • asking employees to stay home from work and social engagements when sick.
Depending on the severity of the pandemic, social distancing measures are implemented early in the pandemic and maintained through the pandemic.
✍
ii. Social distancing
Public health can ask workplaces and post secondary institutions to make changes to their environments and practices that reduce contacts between adults, such as: • spacing employees/students two metres* (6 ft.) apart • allowing employees/students to use computer technology to work/study from home • limiting the number of people in a work/study setting at any given time • conducting meetings/academic lecturers via television, radio, mail, Internet, teleconference or videoconference instead of face-to-face • staggering employee working hours and academic lectures to reduce the number of people on the transit system at the same time • establishing liberal absence/sick leave policies so workers who are ill or have ill family members can remain away from work until symptoms in the household have resolved • cohorting students in dormitories, in order to keep student with influenza separate from other students.
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iii. Restricting public gatherings
Public health can issue orders restricting or discouraging social and other large gatherings – particularly those held indoors, including: • sporting events • faith based ceremonies • dances and other social activities. * Droplets from a coughing or sneezing person can be expelled a distance of about two metres, and may be inhaled by someone within that two metre distance.
6.4 Effectiveness of Public Health Measures The US Centers for Disease Control in its 2007 report, Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States – Early, Targeted, Layered Use of Nonpharmaceutical Interventions, has analyzed the effectiveness of different public health measures in reducing the spread of an illness like pandemic influenza.
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According to that analysis, case and contact management are only partially effective because people are infectious before they develop symptoms and not all contacts will be identified before they develop symptoms. The most effective measures are:
• hand hygiene • social distancing strategies in daycare. A recent study found that children (ages 25 to 36 months) in group care with six or
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more children were 2.2 times as likely to have an upper respiratory tract illness as children reared at home or in smallgroup care (< six children).
• school closures – particularly when combined with other measures that disrupt young people’s other social networks, such as meeting at the mall. (For example, a nation-wide school closure in Israel during an influenza pandemic resulted in significant decreases – 42% – in diagnoses of respiratory infections.)
• low cost, sustainable social distancing strategies that disrupt adult networks and suppress the spread of the virus
• travel restrictions that close large hub airports (as opposed to smaller airports). The success of any single public health measure depends on a variety of factors such as:
• The epidemiology of the strain. If the virus has a longer incubation period than seasonal influenza viruses, local public health authorities will have more time to identify and isolate cases before the virus spreads to others.
• The timing of the measure. For individual public health measures, such as case and contact management, to be effective, they must be used aggressively during the alert phases of the pandemic (i.e., phases 4 and 5) to follow-up confirmed and suspected cases.
• Public compliance with the measure. Past experience with influenza pandemics indicates that people generally comply with personal protective measures at the beginning of the pandemic but, as more people became ill, compliance wanes. To slow the spread of the virus, it will be
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important to keep the public engaged and encourage compliance. According to the CDC document, each of the public health measures described here will be only partially effective if implemented alone. Modeling exercises, however, indicate that these measures implemented together as part of a comprehensive approach will be more effective in reducing transmission, and should be implemented simultaneously. Measures are also likely to be more effective when implemented early and quickly, and when used with vaccines and a targeted antiviral strategy (see Chapter 9).
6.5 Risks and Mitigating Strategies While each public health measure may be partially effective, all – with the exception of public education – have some risks. For example, travel restrictions, voluntary isolation and quarantine in case and contact management, school closures and social distancing measures in the community will all take people out of the workforce and disrupt services and the economy. School and daycare closures are a particular concern because parents would have to stay home from work to look after children. This would have a negative economic impact on families – particularly low income families who cannot afford to lose incomes for four to 12 weeks. It would be disruptive to businesses and could affect access to essential services. In addition, adolescents who are not at school may congregate in other places (e.g., malls), providing other ways for the virus to spread. These risks must be weighed against the economic and social costs of an unchecked pandemic. The risks can also be balanced by using mitigating strategies, such as: developing child-minding strategies for workers in
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essential industries; using high school and university students to look after younger children, freeing parents to work; allowing parents to work from home (e.g., using Internet technologies or teleconferences); encouraging small groups of families to share child care needs; and providing income supports for low income families who have to take time off work. As the CDC notes, family-sized gatherings of children are acceptable, but any arrangements that recreate the typical density of children in school classrooms should be avoided. Developing and publicizing mitigation strategies early will help ensure better public compliance if and when public health measures must be used.
6.6 A Severity-based Approach to Public Health Measures Assumptions A proportional response. Because public health measures are potentially socially and economically disruptive, Ontario (as stated in the ethical framework and in keeping with the precautionary principle) will use measures that are proportional to the risk of public harm and necessary to protect the public good (i.e., the least restrictive means necessary to achieve public health goals). Coercive measures will be used only when less restrictive measures fail to protect public health. A severity-based approach. The types and extent of public health measures used during an influenza pandemic will depend
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on the severity of the pandemic, based on death rates:
• <0.1% case fatality rate = a mild pandemic
• from 0.1% to <1.0% case fatality rate = a moderate pandemic
• 1.0% or higher case fatality rate = a severe pandemic. OHPIP’s plan for public health measures is based on the assumption that, by the time the pandemic arrives in Ontario, we will have information about its severity. Figure 6.1 illustrates a severity-based approach where the type and extent of public health measures varies depending on the severity of the pandemic. For example:
• During a mild pandemic, when relatively few people are dying from the pandemic strain, public health would NOT do active contact management. Social distancing measures in schools, daycare and the community would be limited to reinforcing individual measures, such as good hand hygiene and cough etiquette.
• During a moderate pandemic, public health would encourage social distancing measures in schools, daycares and public places – such as avoiding mixing groups and keeping students two metres apart – and may consider some restrictions.
• Only in a severe pandemic would public health recommend restricting public gatherings and closing schools and daycares for four or more weeks.
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Figure 6.1: Public Health Measures By Pandemic Severity
* Reassess length of time that schools should remain closed based on the epidemiology of the virus.
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A resources-driven approach. Public health units will have limited capacity to do individual (one-to-one) case/contact management. Because of resource limitations, public health will do individual case/contact management only when it is warranted based on the severity and stage of the pandemic (i.e., once there is community spread, individual case/contact management will no longer be effective or practical). Once their resources/capacity are overwhelmed, public health units will focus on group/public messaging to achieve the same ends.
6.7 Triggers for Public Health Measures
A consistent approach, with some flexibility to respond to local needs. The Chief Medical Officer of Health will make specific recommendations about the measures to be used province wide. Public health units will use the same triggers to activate the same measures; however the timing of measures may vary from health unit to health unit depending on the phase and severity of the pandemic in each part of the province. While there may be legitimate reasons for some variation in the public health measures used in different health units (i.e., some measures may be more effective in rural or isolated communities than in urban areas), it is important to have as much consistency as possible. This will help ensure public confidence and compliance, and reduce confusion.
6.8 Communicating about Public Health Measures
Public health measures are likely to be most effective when used early in the pandemic and implemented quickly. Figure 6.2 illustrates the triggers for initiating each type of public health measure described in Figure 6.1 and the duration of their use. Note: the trigger for each public health measures is the same regardless of the severity of the pandemic; however the severity determines the intensity of the public health measure.
During a pandemic, Ontarians will look to public health officials for information and direction, and it is essential for public confidence that the messages provided by public health, health care providers and the media come from a credible source, and be consistent and accessible. Public health officials will work closely with communications experts to deliver information in effective ways (e.g., media campaigns, posters, pamphlets, special telephone lines and websites). For more information on communications, see Chapter 12.
A targeted approach. Depending on the epidemiology of the virus, some populations may be at greater risk, such as Aboriginal peoples, seniors and children. Ontario will use information on the epidemiology of the virus (e.g., attack rates in different populations) to develop targeted public health interventions.
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Figure 6.2: Triggers for Public Health Measures
6.9 Next Steps Ontario will continue to assess the potential effectiveness of different public health measures in the event of an influenza pandemic. To help health units implement public health measures consistently and the public comply with these measures, Ontario will develop the following guidelines:
• case and contact management during a pandemic for public health units
• the impact of public health measures and mitigating strategies on employers and businesses
• public health measures for daycares • public health measures for elementary and secondary schools
• public health measures for post secondary schools
• public health measures for individuals and families.
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7. Occupational Health and Safety Measures and Infection Prevention and Control in Health Settings [H]e demonstrated for them an innovation he had experimented with: the wearing of gauze masks by patients with respiratory disease … Welch called the mask “a great thing … an important contribution in prevention of spray infections.” He encouraged Capps to write an article for the Journal of the American Medical Association and advised Pearce to conduct studies of the masks’ effectiveness.” The Great Influenza, John M. Barry
Occupational health and safety measures and infection prevention and control measures can help protect health workers and patients from exposure to the influenza virus in health settings. This chapter was developed in collaboration with the Ministry of Labour and describes: the regulatory framework and legislated requirements, roles and responsibilities for workplace health and safety; the risks of influenza transmission in the workplace; the importance of education; the hierarchy of control measures that can reduce the spread of influenza in health settings; and recommended infection prevention and control measures. Recommendations are based on the precautionary principle as set out by Justice Campbell in the final report of the SARS Commission (Spring of Fear, December 2006) which stated: “We cannot wait for scientific certainty before we take reasonable steps to reduce risk.”
7.1 Objective
To ensure health workers have access to appropriate training, infection prevention and control practices, personal protective equipment, and other supports to reduce exposure to influenza in the workplace. To provide information on infection prevention and control practices to reduce spread of influenza in health care settings.
7.2 The Regulatory Framework for Occupational Health and Safety i. Occupational Health and Safety Act Health care facilities are required to comply with applicable provisions of the Occupational Health and Safety Act (OHSA) and its Regulations. Employers, supervisors and workers have rights, duties and obligations under the OHSA. To see the specific requirements under the OHSA go to: http://www.e-laws.gov.on.ca/html/ statutes/english/elaws_statutes_ 90o01_e.htm The Occupational Health and Safety Act places duties on many different categories of individuals associated with workplaces, such as employers, constructors, supervisors, owners, suppliers, licensees, officers of a corporation and workers. A guide to the requirements of the Occupational Health and Safety Act may be found at: http://www.labour.gov.on.ca/english/hs/ ohsaguide/index.html In addition, the OHSA section 25(2)(h) requires an employer to take every precaution reasonable in the circumstances for the protection of a worker. Specific requirements for certain health care and residential facilities may be found in the Regulation for Health Care and Residential Facilities. Go to:
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http://www.e-laws.gov.on.ca/html/regs/ english/elaws_regs_930067_e.htm
equipment, protective devices or clothing required by the employer.
There is a general duty for an employer to establish written measures and procedures for the health and safety of workers, in consultation with the Joint Health and Safety Committee or health and safety representative, if any. Such measures and procedures may include, but are not limited to, the following:
Health care associated infections in health care workers, acquired as a result of workplace exposures, are occupational illnesses that must be reported to the Ministry of Labour, to the workplace Joint Health and Safety Committee or health and safety representative, and to the trade union, if any, in accordance with the Occupational Health and Safety Act s.52(2) and the Regulation for Health Care and Residential Facilities s.5(5)."
safe work practices
safe working conditions
proper hygiene practices and the use of hygiene facilities
the control of infections.
At least once a year the measures and procedures for the health and safety of workers shall be reviewed and revised in the light of current knowledge and practice. The employer, in consultation with the Joint Health and Safety Committee or health and safety representative, if any, shall develop, establish and provide training and educational programs in health and safety measures and procedures for workers that are relevant to the workers’ work. A worker who is required by his or her employer or by the Regulation for Health Care and Residential Facilities to wear or use any protective clothing, equipment or device shall be instructed and trained in its care, use and limitations before wearing or using it for the first time and at regular intervals thereafter and the worker shall participate in such instruction and training. The employer is reminded of the need to be able to demonstrate training, and is therefore encouraged to document the workers trained, the dates training was conducted, and materials covered during training. Under the Occupational Health and Safety Act, a worker must work in compliance with the Act and its regulations, and use or wear any
For more information, please contact your local Ministry of Labour office. A list of local Ministry of Labour offices in Ontario may be found at http://www.labour.gov.on.ca/ ii. Workplace Safety and Insurance Act The Workplace Safety and Insurance Act sets out requirements designed to prevent workrelated injury or disease and to respond to injured/ill workers. Employers must notify WSIB about a workplace injury or illness within three days. The notice must include such details as steps taken to prevent a recurrence. For more information, see the WSIB website: http://www.wsib.on.ca/wsib/wsibsite.nsf /Public/EmployersInjuryandillness Ontario’s Workplace Safety and Insurance Board (WSIB) plays a key role in the province’s occupational health and safety system. The WSIB administers no-fault workplace insurance for employers and their workers and is committed to the prevention of workplace injuries and illnesses. The WSIB provides disability benefits, monitors the quality of health, and assists in early and safe return to work for workers who are injured on the job or contract an occupational disease.
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Ontario’s designated health and safety associations (funded by the WSIB) provide training programs, products, and consulting services to the province’s employers and workers. The Ontario Safety Association for Community & Healthcare (OSACH), and the Workers Health & Safety Centre (WHSC) are not-for-profit organizations, designated as Safe Workplace Associations under the Workplace Safety and Insurance Act (S.O.1997). For more information on products and services available at OSACH and the WHSC, see their web sites: http://www.osach.ca or http://www.whsc.on.ca. For a complete listing of products and services available from all of Ontario's designated Safe Workplace Associations, see: http://www.preventiondynamics.com/. iii. Emergency Management and Civil Protection Act The Emergency Management and Civil Protection Act gives the Lieutenant Governor in Council and the Premier special powers to deal with declared emergencies in Ontario. Under this Act, orders can be issued authorizing persons to provide services during an emergency. Note: Although the Emergency Management and Civil Protection Act provides special powers, the Occupational Health & Safety Act cannot be overruled in any emergency because worker safety is paramount. All roles, responsibilities, duties, and authority outlined in the OHSA remain intact during an emergency. In the event of any conflict with the Emergency Management and Civil Protection Act, the OHSA prevails. iv. Health Protection and Promotion Act Under the Health Protection and Promotion Act, when the Chief Medical Officer of Health is issuing a directive to health care practitioners, he or she must consider the
precautionary principle in determining whether there exists or may exist an immediate risk to the health of persons anywhere in Ontario as a result of an outbreak of an infectious or communicable disease and, in the limited situation where the proposed directive relates to worker health and safety, determining the use of any protective clothing, equipment or device.
7.3 The Transmission of the Influenza Virus Health workers providing care and/or services to individuals with influenza will be at risk of exposure to the virus in both the health care setting and in the community. Influenza is primarily droplet spread: it can be directly transmitted from person-toperson when people infected with influenza cough or sneeze, and droplets of their respiratory secretions come into contact with the mucous membranes of the mouth, nose and possibly eyes of another person. Particles expelled by a coughing or sneezing person can travel some distance and may be inhaled by someone who is within two metres of a coughing or sneezing person (short-range transmission)1. Because the virus in droplets can survive for extended periods of time on surfaces or hands, the virus can also be contact spread: people can acquire influenza indirectly by touching contaminated hands, surfaces and objects, and then touching their mouth, nose or eyes. The risk to health workers in the workplace may be higher when staff are performing 1
Council of Canadian Academies Report of the Expert
Panel on Influenza and Personal Protective Respiratory Equipment Influenza Transmission and the Role of Personal Protective Respiratory Equipment: An Assessment of the Evidence. December 2007.
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aerosol-generating procedures on patients with influenza-like illness or performing lab procedures that generate aerosols because droplets containing influenza virus may become aerosolized and can be spread through the air. The issue of whether influenza can also be spread by airborne transmission in other situations (i.e., other than during procedures that generate aerosols) is controversial. Current scientific literature and experience with other influenza viruses does not conclusively confirm or rule out airborne transmission. (For a balanced review of the literature, see: Brankston et al. Transmission of influenza A in human beings Lancet Infect Dis 2008; 7(4):257-65; and the Council of Canadian Academies Report of the Expert Panel on Influenza and Personal Protective Respiratory Equipment Influenza Transmission and the Role of Personal Protective Respiratory Equipment: An Assessment of the Evidence available at http://www.scienceadvice.ca/publications. php.) In Ontario, employers should take all reasonable steps to protect health workers from exposure to the pandemic strain of influenza in their workplace. Workplace health and safety measures will be particularly important in the early phase of a pandemic, when there are only a small number of cases and there may be an opportunity to contain the virus and slow community spread. Once the pandemic strain is widespread in the community, health workers and all others will be at risk outside their workplace, and strict workplace controls will not prevent community-based transmission. However, the risk of community-based transmission does not relieve employers of their obligation to take every reasonable precaution to protect workers in the workplace.
7.4 Education and Training To ensure that health workers have the knowledge and skills to reduce influenza transmission, employers must provide appropriate education and training. Ongoing education and support are key to workplace health and safety. All education programs must be developed in consultation with and reviewed by the Joint Health and Safety Committee/health and safety representative. All employers should:
assess the education and training needs of staff related to infection prevention and control and occupational health and safety
provide initial and ongoing education and training for all staff in: •
the principles and procedures of infection prevention and control
•
the hierarchy of controls used to reduce the spread of influenza
•
the correct use of personal protective equipment.
MOHLTC has been developing influenza pandemic training curricula based on the learning objectives set out in Figure 7.1. For updates, please monitor the ministry website at: http://www.health.gov.on.ca/pandemic.
7.5 Risk Assessment To identify and implement measures to protect workers from the risk of health care acquired pandemic influenza, all employers should conduct a risk assessment in consultation with the Joint Health and Safety Committee/Health and Safety Representative. .
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Figure 7.1: Learning Objectives for Pandemic Influenza Training for Health Workers
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The purpose of a risk assessment is to determine the likelihood of an employee being exposed to a hazard and the potential consequence of that exposure. The risk assessment should also consider the number of staff and the job classifications that may be directly or indirectly exposed to the hazard. The outcome of a risk assessment is then used to make informed decisions and develop action plans for appropriate infection control measures and procedures, personal protective equipment, education and training. These measures and procedures should be reviewed frequently – at least annually – based on reassessment of risk. A risk assessment must be a “dynamic tool” that organizations use to help them adapt to new conditions and to protect the health and safety of health care workers. The risk assessment should be conducted by people who have training/responsibility for infection control (e.g., person responsible for infection control in an institution, Ontario’s Regional Infection Control Network, infection control practitioners, pulmonary disease specialists, occupational health and safety professionals, environmental services). The risk assessment should be conducted in consultation with the Joint Health and Safety Committee/Health and Safety Representative. The risk assessment should take into account the precautionary principle, as set out by Justice Campbell in the final report of the SARS Commission. When there is uncertainty about the consequences of exposure, settings should assume the potential risks are high. Table 7.1 provides an example of a simple risk assessment matrix.
Table 7.1: Risk Assessment Matrix Very Likely
Moderately Likely
Unlikely
High
A
A
B
Medium
A
B
B
Low
B
B
C
Likelihood of exposure
Unlikely
Moderately likely
Very likely
Likelihood of Exposure Consequence of Exposure
Notes: Using this matrix, hazards with the greatest likelihood of exposure (very likely) and the greatest potential consequence (high) would be considered the highest risk and should be the first priority (A) for stringent control measures (e.g., identify staff performing aerosol generating procedures). Hazards with moderate likelihood of exposure and medium consequence would be a lower priority (B) and may require fewer/less stringent control measures. Hazards with the least likelihood of exposure (unlikely) and the lowest consequence (low) of exposure (C) will not be considered a priority and will require the fewest control measures. Risk can be reduced by: decreasing the likelihood of exposure and/or reducing the consequence of exposure. The risk assessment matrix can be used to assess individual job tasks or all the job tasks within a job classification. Some of the factors to be considered in conducting a risk assessment for pandemic influenza include:
type of infectious agent
infectious person (e.g., severely ill, unable to comply with cough etiquette, such as children or people who are cognitively impaired)
pathogenicity of the infectious agent, including disease incidence and potential severity of illness (e.g. mild, moderate,
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severe infection, and associated morbidity and/or mortality).
aerosols, such as intubation, bronchoscopy, autopsy, laboratory manipulation-centrifuging, viral manipulation)
route of transmission - influenza is spread primarily through short-range droplet transmission within two metres – (long range transmission is possible but its relative importance is unknown) and through contact transmission
estimated survival time of the infectious agent in the environment.
effectiveness and integrity of existing engineering controls.
availability and appropriate use of personal protective equipment.
number and job classifications of workers potentially directly / indirectly exposed.
knowledge and training of potentially exposed workers.
work processes (i.e. risk to health care workers is higher when staff are performing procedures that generate
proximity of worker to infected individuals
deficiencies in infection prevention and control safe work practices.
individual characteristics of the worker (e.g., immunocompromised, immunization status).
The concept of a risk assessment is not unique to influenza pandemic Table 7.2 provides a sample of elements to consider as part of a risk assessment for pandemic influenza as well as other elements related to infection prevention and control. This list is not all-inclusive and should be tailored to meet the needs of the organization.
Table 7.2: Sample Risk Assessment Checklist for Pandemic Influenza Element
yes
no
n/a
Recommendations (engineering controls, administrative controls, PPE, education and training)
Pandemic Alert Status Has a pandemic alert been declared by the Public Health Agency of Canada in conjunction with a Pandemic Period WHO alert of 6? Has the MOHLTC declared a pandemic alert (i.e., clusters of novel virus activity in Ontario)? Has an infectious agent been present? Screening policies and procedures for ILI for patients, staff and visitors are initiated with PPE for screeners. Patients/residents with ILI are placed in a separate room or cohorted. Internal and external reporting procedures are in place for reporting ILI in clients and staff. Clients with symptoms of ILI are asked to perform hand hygiene, wear a surgical mask and remain in a separate area or at a distance from other clients and staff.
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Patients/residents with ILI can comply with cough etiquette. Health Care Worker Staff with direct patient contact have been identified. Staff with indirect patient contact have been identified. Staff who perform aerosol generating procedures have been identified. Staff report occupationally acquired ILI to their supervisors. Supervisors/employers report occupationally acquired ILI to JHSCs/Health and Safety Reps, WSIB and MOL. Return to work policies and procedures are in place. The immune status of the worker is known. Engineering Controls HVAC systems are properly maintained and inspected to reduce risk of transmission. There are accessible hand hygiene stations in appropriate locations with signage and instructions for staff, clients, visitors and volunteers on when and how to practice hand hygiene. Airborne Infection Isolation Rooms (AIIR) are available for aerosol generating procedures. Biological Safety Cabinets are available for aerosol generating laboratory procedures. Administrative and Work Practices Hand hygiene is performed before seeing the client, after seeing the client, and after removing and disposing of PPE Invasive ventilation procedures that could result in coughing are avoided on clients with ILI when possible. Only experienced staff perform aerosol generating procedures on clients with ILI if required. Close contact is minimized by sitting beside rather than in front of a symptomatic client. The work environment is kept clean; contaminated areas are cleaned and then disinfected after each client visit. Visibly soiled surfaces should be cleaned and disinfected. When transferring a client identified with ILI information is provided/received to/from the other organization regarding the assessment. Personal Protective Equipment Gowns, gloves, face protection (if risk of splashing or spraying) are worn by staff if indicated by routine practices. N95 respirators are available, workers are fit tested, and know how to conduct seal checks.
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Workers know how to properly don and doff personal protective equipment.
7.6
The Hierarchy of Controls
Protection of workers from infectious diseases may be best achieved using a hierarchy of controls (i.e., at the source, along the path and with the worker).
The following are examples of engineering controls:
physical barriers, including acrylic partitions (or sneeze guards) in triage or waiting areas or other high risk zones
space/design plans for wards and waiting areas that keep sneezing and coughing patients at least two metres away from other patients if possible, or have separate areas for people with ILI
equipment such as sinks, tissues and disposable towels in every patient room as well as alcohol-based hand rub (ABHR) and no-touch trash cans in key locations throughout the setting
surfaces in patient care areas that are easy to clean – combined with appropriate cleaning procedures (administrative and work practice)
ventilation systems that are designed and maintained in accordance with CSA Standards and Special Requirements for Heating, Ventilation and Air Conditioning (HVAC) Systems in Health Facilities and the American Society of Heating, Refrigeration, Air–conditioning Engineers (ASHRAE) standards (see http://www.csa.ca and http://www.ashrae.org/)
airborne infection isolation rooms (AIIR) or negative pressure rooms are preferred, if available, for aerosol generating procedures and should be monitored for compliance with CSA standards prior to use. (Note: negative pressure rooms are NOT required for routine care) [see Table 7.3]
Reducing the risk of influenza transmission in the workplace requires a comprehensive strategy that includes:
engineering controls that make the work environment or setting safer
administrative and work practices that reduce the risk of infection
personal protective equipment used by health workers
other infection prevention and control measures that protect patients and visitors as well as health workers.
Engineering Controls Engineering controls are the first and most effective line of defense against short-range inhalation transmission because they involve permanent changes in the health setting that reduce exposure to influenza, and they eliminate the risk of “human error” or non-compliance with recommended practices or use of personal protective equipment. Developing physical environments that can reduce the spread of the disease is also cost- effective, and should be a priority when building or renovating facilities. Existing facilities should review their capital plans to assess the impact of the physical environment on health and safety, and make improvements (e.g., traffic flow, barriers, positioning of chairs in waiting areas) when possible.
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Administrative and Work Practices Administrative and work practices include ways of organizing and providing care and services – at the system level and the individual organization level – that reduce the risk of exposure to influenza. When developing work practices, employers should consult with health workers who have direct experience with the tasks and can provide valuable advice. Healthcare workers should wear N95 respirators when entering a room with patients with influenza-like-illness during a pandemic. The following are examples of administrative and work practices that should be used as much as possible and practical in all settings:
patient care areas). See Chapter 7A for sample screening tools.
work practices such as having health care workers wear N95 respirators when entering a room/area with patients with ILI.
policies to delay non-emergency highrisk procedures until the patient’s ILI symptoms have resolved.
cohorting policies including:
managing patient flow. During an influenza pandemic, the health system will make significant effort to manage patient flow by keeping individuals with influenza symptoms separate from people without ILI symptoms. At the organizational level, employers should assess patient/traffic flow patterns and make changes, directing people with symptoms of ILI to certain entrances and exits, and limiting access to certain parts of the health setting. These measures will limit the risk of exposure to certain areas and help the setting maintain its regular operations (i.e., companies can continue to deliver supplies, people who do not exhibit symptoms of influenza can enter the setting without being exposed).
screening policies and procedures for influenza-like illness (ILI) for patients, staff and visitors that would direct them to take appropriate steps to reduce risk (e.g., instruct patients with ILI to put on a surgical mask, perform hand hygiene, and keep at least 2 metres away from other patients, ask ill visitors not to enter
•
separating patients with ILI from other patients (e.g., different waiting areas, assigning patients with confirmed/suspected influenza to one ward or floor).
•
designating equipment to be used only with influenza patients.
•
bringing services that would normally be delivered in a common area to influenza patients – such as meals (in a long-term care home), portable x-ray equipment – to reduce the need for patients to be moving throughout the facility.
•
deploying staff to designated areas to reduce mixing and exposure (Note: this strategy will not be effective when influenza is widespread in the community; however, community transmission does not relieve employers of the responsibility to take all reasonable precautions to protect workers in the workplace.)
staffing plans that: •
identify staff who may be at high risk of complications from influenza so they can be offered work assignments that do not knowingly expose them to the influenza virus (Note: during a pandemic, personnel at high risk should
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provide Occupational Health Services with medical documentation supporting their requirement for accommodation. Appropriate alternative work should be provided where available.) •
•
set out how staff will be deployed and managed during a pandemic (see Chapter 8). cohort recovered staff to care for influenza patients.
HR policies that encourage ill employees to stay home. All employers should establish a clear expectation that staff do not come into work when they have ILI symptoms and support this expectation with appropriate attendance management policies. For example, all employers should: provide sick leave benefits for all workers (either in the form of paid sick days for full-time staff or in compensatory wage rates in lieu of benefits to part-time staff); avoid reward programs for workers who have no sick days; avoid penalizing workers for taking sick days; and actively exclude workers who are ill (i.e., send workers home who arrive at work ill). social distancing procedures that minimize face-to-face contact between health workers in situations where they are not wearing PPE, such as arranging to meet by e-mail and teleconference instead of in person, and planning use of cafeterias and other common staff areas to allow for greater distance among staff. processes for handling and cleaning equipment and clothing that reduce possible exposure (See Chapter 7A for guidelines on environmental cleaning).
Cleaning Precautions Health workers should use the following precautions when cleaning rooms of influenza patient:
wear gloves in accordance with facility policies for environmental cleaning
use an N95 respirator wear face and eye protection if cleaning near a coughing patient or when cleaning a coughing patient’s room gowns are usually not necessary for routine cleaning of an influenza patient’s room but should be worn if the employee’s clothes or uniform could become soiled with blood or potentially infectious materials.
Personal Protective Equipment (PPE) Table 7.3 lists the personal protective equipment suggested in different situations. Employers should:
stockpile a four-week supply of appropriate personal protective equipment required for Routine Practices, Droplet Precautions, Contact Precautions and Airborne Precautions (The Ministry of Health and Long-Term Care will also stockpile a four-week supply of personal protective equipment.)
maintain a written respiratory protection program, and provide fit testing and training for staff using N95 respirators (Note: the use of N95 respirators are being recommended by all health care workers who enter a room or area with patients with ILI to protect them from the possibility of short or long distance transmission.)
ensure that workers have quick easy access to the personal protective equipment required. All units and crash carts should be equipped with: N95
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respirators, eye protection, gloves, gowns; a manual resuscitation bag with hydrophobic submicron filter; and in-line suction catheters.
develop procedures and provide training to help ensure staff put on, use, take off and dispose of personal protective equipment. instruct patients with ILI symptoms (i.e., coughing, sneezing) to perform hand hygiene and wear surgical/procedure
masks (if their condition allows) when in common areas, such as waiting rooms, triage areas, and emergency vehicles, or when being transported within or between facilities. Although N95 respirators are not routinely required for seasonal influenza, in keeping with the precautionary principle, they are recommended for use during an influenza pandemic and for aerosol-generating procedures (See Table 7.3.)
Table 7.3: Personal Protective Equipment Suggested for Patient Care During an Influenza Pandemic NOTE: PPE is only one component of the hierarchy of infection prevention and control measures required to protect health workers. Gloves, gowns and/or masks (during seasonal influenza) should be used where indicated by routine practices and additional transmission-based precautions based on a workplace specific risk assessment conducted in consultation with the Joint Health and Safety Committee.
Seasonal Influenza (including ILI1)
Pandemic Influenza (including ILI1)
Aerosol Generating Procedures on Patients with Pandemic Influenza* (including ILI1)
no risk factors for airborne diseases Patient accommodation
Single patient room AIIR2 not required
Single patient room or cohort AIIR2 not required
In AIIR2 if available
Precautions
Routine/Droplet/Contact
Routine/Droplet/ Contact
Routine/Droplet/ Contact/ Airborne
Hand hygiene
Yes
Yes
Yes
Gloves
If indicated by Routine Practices3
If indicated by Routine Practices3
If indicated by Routine Practices3
Gown
If indicated by Routine Practices3
If indicated by Routine Practices3
If indicated by Routine Practices3
Surgical mask for HCW
Yes
No
No
N95 respirator for HCW
Not routinely
Yes4
Yes4
Eye Protection
If indicated by Routine Practices3
If indicated by Routine Practices 3
Yes
Surgical Mask on Patient
At triage and if outside of room
At triage and if outside of room
Not applicable
Notes to table: 1 ILI: Influenza-like illness 2 AIIR: Airborne infection isolation room 3 See Provincial Infectious Diseases Advisory Committee (PIDAC) resources on routine practices. 4 The use of N95 respirators are being recommended to protect health workers from the possibility of short-distance fine droplet aerosol transmission. See Council of Canadian Academies Report. *Detailed information on the types of aerosol-generating procedures and personal protective equipment requirements are provided in World Health Organization interim guidelines for infection prevention and control of epidemic and pandemic-prone acute respiratory diseases in health care – June 2007, pp 43-44. Available at: http://www.who.int/csr/resources/publications/WHO_CD_EPR_2007_6/en/index.html
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A worker who is required to wear or use any protective clothing, equipment or device shall be instructed and trained on its care, use and limitations before wearing or using it for the first time and at regular intervals thereafter and the worker shall participate in such instruction and training. The employer is reminded of the need to be able to demonstrate training, and is therefore encouraged to document the workers trained, the dates training was conducted, and the materials covered during training. In all settings where care is delivered, staff should follow procedures for managing and disposing of equipment that are consistent with the Public Health Agency of Canada guidelines (see http://www.phacaspc.gc.ca/publicat/ccdr-rmtc/98pdf/ cdr24s8e.pdf and Ontario’s Environmental Protection Act and regulations).
resuscitation of patients with influenza (emergency intubation, CPR)
care of patients with influenza-related pneumonia and other complications of influenza, if the person is still thought to be contagious.
7.6 Applying the Hierarchy of Controls in Different Health Settings The principles of the hierarchy of controls apply to all health settings but each setting will face unique issues. For example:
Long-term care homes may have residents returning from higher levels of care, who should be screened and monitored for symptoms of ILI when they return to the home. Room mates of residents who develop influenza should be treated as close contacts, and monitored. Cohorting of residents with ILI may be considered. See Chapter 19.
Home care programs will have to rely more heavily on administrative/work practices, infection prevention and control measures, staff and client education, and personal protective equipment since implementation of engineering controls may be more limited in private residences.
Coping with Equipment Shortages
During a pandemic, health settings may experience PPE shortages. In those cases, employers will assess services and reprioritize to ensure staff involved in high risk activities are protected at all times, including staff providing:
care for patients with active pulmonary or laryngeal tuberculosis
aerosol-generating procedures on patients with influenza
Figure 7.2 illustrates the planning and implementation of the hierarchy of controls by pandemic phase.
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Figure 7.2: Hierarchy of Controls by Pandemic Period
Note: The hierarchy of controls used in any setting should be based on a risk assessment conducted in consultation with the Joint Health and Safety Committee, infection prevention and control and occupational health services.
7.7 Infection Prevention and Control Measures Employers should implement appropriate infection prevention and control measures. These measures are designed to protect workers, patients and visitors from exposure to the pandemic strain of the virus. They include:
access to infection prevention and control expertise
ongoing surveillance programs for febrile respiratory illnesses
immunization policies that encourage staff providing care and/or services to patients/residents/clients to be immunized against seasonal influenza
used with influenza, including hand hygiene, routine practices, droplet and contact precautions for routine care, and airborne precautions when performing aerosol-generating procedures. In addition to droplet precautions, OHPIP recommends the use of N95 respirators (instead of surgical masks) when in a room/area with influenza patients. This recommendation is based on the precautionary principle and is designed to protect workers from the risk of fine droplet spread. Hand Hygiene
Health workers should follow rigorous hand hygiene measures, as follows:
Perform hand hygiene before seeing the patient; after seeing the patient and before touching one’s face; and after removing and disposing of personal protective equipment.
When hands are visibly dirty or contaminated with respiratory secretions, wash with soap and water.
consistent use of routine practices and droplet, contact and airborne precautions as appropriate.
Infection Prevention and Control for Health Care Workers To protect workers from risk of occupational exposure to the pandemic influenza strain, OHPIP recommends the precautions usually
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If gloves are worn, perform hand hygiene immediately after removing gloves.
wear gowns during procedures and patient care where clothing might be contaminated
If hands are not visibly soiled, use an alcohol-based hand rub containing between 60 and 90% alcohol to routinely decontaminate hands in all clinical situations including contact with a patient with ILI.
When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and pat dry thoroughly with a disposable towel. Use a disposable towel to turn off the faucet.
use standard operating procedures to handle, clean and then disinfect patient care equipment, clean patient rooms, and handle soiled linen; prevent needlestick/ sharp injuries; and address environmental cleaning, spillsmanagement, and handling of waste.
When decontaminating hands with an alcohol- based hand rub, apply product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the amount of product to use.
Commercial, pre-packaged, cleaning or disinfectant wipes that are easily accessible to all workers allow efficient cleaning of equipment and surfaces between patients. See PIDAC fact sheets on: hand hygiene and cleaning disinfection and sterilization. The fact sheets include the appropriate cleaning agents to use and contact time. See: http://www.health.gov.on.ca/english/ providers/program/infectious/diseases/ ic_cds.html
How to Remove Personal Protective Equipment (PPE) After the health worker has completed patient care and is
Note: Sinks that patients use may be heavily contaminated and should not be used by health workers for hand hygiene unless no other alternative is available.
away from the patient’s room or treatment area: Remove gloves and discard using a glove-to-glove/skinto-skin technique. Remove gown (discard in linen hamper in a manner that minimizes air disturbance).
Routine Practices
Perform hand hygiene.
When caring for all patients, including patients with influenza or symptoms of ILI, health workers should use routine practices:
Remove eye protection and discard or place in clear plastic bag and send for decontamination as appropriate.
Perform hand hygiene.
wear a mask and protective eye wear when working in the patient room or near a coughing patient wear appropriate gloves when likely to have contact with body fluids or to touch contaminated surfaces
Remove respirator and discard.
This is a minimum procedure. If health workers believe their hands have become contaminated during any stage of PPE removal, they should perform hand hygiene before proceeding further.
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perform aerosol generating procedures only when essential
perform aerosol generating procedures in a negative pressure or airborne infection isolation room (AIIR) if available. Note: negative pressure rooms are NOT required for other care/procedures for patients with pandemic influenza (US Centers for Disease Control, October 2006)
clean all contaminated surfaces and equipment following a high risk procedure before leaving the room and before removing personal protective equipment. Do not re-enter the room until it has been cleaned
restrict the number of persons entering the patient’s room to the minimum required for patient care and support.
Droplet and Contact Precautions
During a pandemic health workers providing care and/or services for patients/residents/clients with influenza or ILI should use droplet and contact precautions:
use examination procedures that minimize contact with droplets (e.g., sitting next to rather than in front of a coughing patient when taking a history or conducting an examination)
take only the equipment required to provide care into the patient’s room
whenever possible, use disposable equipment and discard it with regular garbage immediately after leaving the patient’s room
clean and disinfect any reusable communal or shared equipment after use (e.g., stethoscope) wear an N95 respirator (this is a modification to droplet/contact precautions based on risk in accordance with infection prevention and control principles). remove Personal Protective Equipment (PPE) properly wipe down any areas touched by a patient with influenza during a visit (e.g., arms of the chair in the waiting room, the examination table, the edge of the desk,).
Airborne Precautions
When providing care and/or services for someone with pandemic influenza or ILI, workers should use the following airborne precautions when performing aerosol generating procedures:
wear an N95 respirator
Infection Prevention and Control Measures for Patients with Influenza/ILI Patients who have influenza symptoms (i.e., fever, cough) who come to a health setting for care should be asked to:
practise hand hygiene: clean their hands using alcohol-based hand rub
wear a surgical or procedure mask and either wait in a separate area or keep at least two metres away from other patients and staff. If the patient cannot tolerate a mask (e.g., children, people with chronic breathing problems, people with dementia), s/he should wait in a separate area or keep at least two metres distance from other patients and be provided with tissues to contain coughs. Each health setting’s capacity to separate patients with symptoms of ILI will depend on space. In crowded waiting areas, precautions like hand hygiene and masks become even more important. If masks are not available, patients should
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thoroughly cleaning surfaces in the home in areas occupied by someone with ILI, focusing on “high touch” items such as taps, doorknobs, light switches, the telephone and bed table, that the ill person has touched that others may also touch
Whenever possible, patients who have influenza symptoms who are admitted to a hospital should:
complying with any public health measures recommended by the medical officer of health (see Chapter 6)
staying home from work or school when ill
be accommodated in a single room if available or cohorted with other influenza patients in designated multibed rooms or wards
covering their mouth when coughing using a tissue or sleeve rather than their hands
have their own hand washing sink, toilet, and bath facilities
not visiting people in hospital or a longterm care home when ill with influenza.
be encouraged to use another method to cover their mouth and nose when coughing or sneezing (e.g., tissue, coughing into sleeve). Patients who have symptoms of influenzalike illness and a travel history to an area with a health alert should be moved immediately out of the waiting room and put in a separate room.
limit their movements and contact with other patients and workers
wear a surgical mask when outside their room.
Infection Prevention and Control Practices for the Public/Visitors Health settings should advise the public/visitors about the steps they can take to reduce the risk of being exposed to influenza, including:
having the annual influenza immunization
practising hand hygiene: washing their hands frequently with soap and water or using alcohol-based hand rub – particularly after coughing or sneezing and when entering and leaving a health setting
keeping at least two metres away from someone who is coughing or sneezing
avoiding activities where large number of people gather in enclosed spaces (e.g., sporting events, concerts)
More information on precautions to be taken by family members providing care for people with influenza at home will be included in the next iteration of OHPIP. The wearing of masks or respirators by the public/people caring for someone who has influenza has not been proven to be an effective means of limiting the spread of influenza during a pandemic. However, if individuals who do not have ILI choose to wear masks, they should:
wear a surgical/procedure mask
learn the proper procedures to put masks on and off
dispose of the mask immediately after removing it and then immediately perform hand hygiene
know how to properly dispose of used masks without contaminating themselves and increasing the risk of infection
understand that masks or any protective equipment is not a substitute for hand hygiene.
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7.7 Psychological Support for Workers During an influenza pandemic, health workers are likely to be working extended or extra shifts in an environment with high levels of stress – caused by the demand for care and fear of the emerging pandemic. As part of pandemic preparedness, employers should develop psychosocial support services that will help health workers and their families cope with fatigue, the discomfort of wearing personal protective equipment for long periods of time, and stress and anxiety. In addition to the services provided by employee assistance programs, employers may consider providing:
counselling
assistance with child care, pet care, meals and other home responsibilities.
Chapter 21 will provide more information on psychosocial support for workers and the public.
7.8 Managing Workers with ILI The Canadian Pandemic Influenza Plan Annex on Infection Control contains the following definition of Fit to Work: “Terminology used in occupational health to communicate a worker’s ability to remain at or return to work. This ability includes three categories: fit for work, unfit for work, fit with restrictions. This categorization allows the occupational health nurse to maintain confidentiality about a worker’s diagnosis, symptoms, and immune status.
Fit for Work - Fit to work with no restrictions.
Unfit for Work – Defined as a medically determinable illness that prevents an employee from performing the regular or modified duties of their occupation.
Fit for work with restrictions - Allows for the re-assignment of duties or reintegration into the workplace in a manner that will not pose an infection risk to the health worker or to other individuals in the workplace.
Recommendations for managing workers with ILI are as follows: 1. Fit for Work Ideally, health workers are fit to work when one of the following conditions applies:
they are well
they have recovered from ILI
they have been immunized against the pandemic strain of influenza
they are on appropriate antivirals.
Health workers who meet these criteria may work with all patients and may be selected to work in units where there are patients who, if infected with influenza, would be at high risk for complications. Whenever possible, unexposed health workers should work with non-ILI patients. Workers should pay meticulous attention should be paid to hand hygiene and Routine Practices and additional precautions, and health workers should avoid touching mucous membranes of the eye and mouth, and should use all required personal protective equipment to prevent exposure to the influenza virus and other infective organisms. 2. Unfit for Work Ideally, staff with ILI should be considered “unfit for work” and should not work; however, in a severe pandemic with resulting staff shortages, they may be asked to work if they are well enough to do so (see 3 below).
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3. Fit to Work with Restrictions Ideally, staff with ILI who are considered “fit to work with restrictions” should only work with patients with ILI. They should NOT be deployed to intensive care areas, nurseries or units with severely immunocompromised patients (i.e., transplant recipients, hematology/oncology patient, patients with chronic heart or lung disease, or patients with HIV/AIDS and dialysis patients). Symptomatic workers should wear masks and pay meticulous attention to hand hygiene at all times.
7.9 Communications During a pandemic, it is critical that frontline staff receive the information they need to work safely. In addition to Important Health Notices, MOHLTC will use a number of different mechanisms to communicate with health workers and stakeholders (e.g., telephone, email, fax, website, videoconferencing, public education, advertising, stakeholder communications, and media relations). The MOHLTC has developed an information cycle for use during a public health emergency, such as a pandemic (see Chapter 12, Figure 12.1). The information
cycle will ensure worker groups and the public/media receive regular timely reports. The MOHLTC will work closely with the Ministry of Labour on communications. The MOHLTC will also work with a group made up of the CMOH, EMU and representatives from the professional associations, labour associations, regulatory colleges and regional offices which will bring forward issues, provide advice to the government, and ensure effective communication with their constituencies. Health workers will be able to call the MOHLTC’s Emergency Management Unit Health Provider Hotline toll-free: 1-866-2122272 and/or visit the website at: http://www.health.gov.on.ca/english/pro viders/program/emu/emu_mn.html
7.10 Summary Figure 7.3 summarizes the range of measures that should be in place to protect health workers during a pandemic. Table 7.4 is a checklist that health employers can use to guide planning for occupational health and safety and infection prevention and control during a pandemic.
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Figure 7.3: Occupational Health and Infection Prevention and Control Practices During the Pandemic Period
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Table 7.4: Occupational Health and Safety/Infection Prevention and Control Pandemic Checklist Task/Activity
Yes/No
Action Required
1. Organization 1.1
Does the organization have a Joint Health and Safety Committee or health and safety representative?
1.2 Is the employer aware of its responsibilities under the OHSA? 1.3 Are supervisors aware of their responsibilities under the OHSA? 1.4 Are workers aware of their responsibilities and rights under the OHSA? 1.5 Has the organization developed occupational health and safety measures and procedures for use during an influenza pandemic in consultation with the Joint Health and Safety Committee or health and safety representative?. 1.6 Does the organization have access to expertise in infection prevention and control? 1.7 Does the organization routinely review and assess its infection prevention and control programs in consultation with the JHSC?. 1.8 Does the employer have a respiratory protection program and are workers trained on the program? 2. Education and Training 2.1 Has the organization incorporated information for workers into its ongoing training programs? 2.2 Do orientation programs for new employees include information on infection prevention and control and occupational health and safety measures during an influenza pandemic? 3. Risk Assessment 3.1 Has the organization completed a risk assessment in conjunction with JHSC to determine workers’ level of risk during an influenza pandemic? 3.2 Has the organization refined education and training plans based on the risk assessment? 3.3 Does the organization have a procedure in place to regularly update risk assessments? 3.4 Does the organization have a respirator protection, education and fittesting program consistent with the Canadian Standards Association “Selection, Use and Care of Respirators”? 4. Hierarchy of Controls 4.1 Has the organization identified and implemented engineering controls that would reduce influenza transmissions? 4.2 Has the organization reviewed and modified administrative and work practices to reduce the risk of influenza transmission? 4.3 Has the organization identified the personal protective equipment that workers will require during an influenza pandemic? 4.4
Does the organization have a four-week stockpile of personal protective equipment?
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5. Infection Prevention and Control 5.1 Does the organization have an ongoing FRI surveillance program? 5.2 Does the organization have immunization policies that encourage workers who provide care and/or services to patients with ILI to be immunized against seasonal influenza? 5.3 Does the organization actively promote hand hygiene and consider it a standard of practice? 5.4 Does the organization actively promote cough etiquette to workers, patients and the public? 5.5 Are workers aware of and trained in the routine practices and droplet, contact and airborne precautions to be used during an influenza pandemic? 5.6 Do workers have easy access to the equipment and supplies they need to consistently use appropriate precautions? 5.7 Have workers who will have contact with influenza patients (based on risk assessment) been fit-tested and trained in the use of N95 respirators? 5.8 Are workers trained in the safe use and removal (i.e., donning and doffing) of personal protective equipment? 6. Managing Workers with Influenza 6.1 Does the organization have a procedure to assess whether workers are fit to work? 7. Psychosocial Support 7.1 Has the organization developed plans to provide psychosocial support for workers during an influenza pandemic? 8. Communications 8.1 Has the organization developed plans and materials to communicate with workers, patients and the public about an influenza pandemic? 8.2 Is there a designated area where workers can obtain information on/be alerted to a potential influenza pandemic?
7.11 Next Steps
information and guidelines for occupational health and safety and infection prevention and control
The MOHLTC, in collaboration with internal and external partners, will:
determine the role of the new Ontario Agency for Health Protection and Promotion in pandemic influenza planning, particularly infection prevention and control
continuously review emerging and evolving science on influenza transmission, and update the recommended controls and measures as appropriate.
continue to work closely with the Ministry of Labour and with the Provincial Infectious Diseases Advisory Committee (PIDAC) to develop
develop training and education programs/modules for health care workers
develop infection prevention and control advice for members of the public caring for people with influenza at home.
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8. Optimizing Deployment of the Health Workforce Doctors and nurses were what was needed. And especially nurses … The Red Cross had divided the country into 13 divisions, and the nursing committee chief of each one has already been told to find all people with any nursing training, not only professionals or those who had dropped out of nursing schools but down to and including anyone who had ever taken a Red Cross course in caring for the sick at home. The Great Influenza, John M. Barry
During an influenza pandemic, health care workers will be called upon to provide care for people who have influenza. They will also be asked to continue to maintain other health care services during a pandemic. But health care workers will also be affected by influenza. Based on the assumptions in this plan, at the peak of a pandemic wave as many as 20 to 25% of health care workers may be absent from work – either because of illness or because of caregiving responsibilities at home. When the demand for care will be greatest, the health system will be hard pressed to maintain its workforce. To optimize the availability of health human resources (HHR) and to ensure patientcentred care during a pandemic, Ontario will take a competency-based approach to HHR planning. The objective of this section of the OHPIP is to explain competencybased HHR planning and its relevance to key stakeholders including local planners, health care providers, health regulatory colleges and volunteer agencies. Employers and unions may also find the section useful for planning. All sectors of the health care system must work together to plan a coordinated and comprehensive approach to optimizing the deployment of the health workforce during a pandemic. There is some concern on the part of health care providers that they may be deployed without being part of the decision-making process. This is not the intent. OHPIP
recognizes the role that self-regulating professions and their regulatory colleges play in determining competencies and establishing standards for safe care, as well as the role of unions in discussions about deploying health care workers and the need to respect collective agreements. The framework for competency-based planning is a guide to a collaborative approach to deploying staff during a pandemic. In the proposed approach, health care planners and employers play a key role in identifying the competencies required during an influenza pandemic, while the professions and health care providers play a key role in assessing their competencies and determining how their knowledge and skills can best be used. The framework described in this chapter and the tools included in Chapter 8A provide an opportunity for planners, providers and volunteers to participate in preparing for an influenza pandemic and to understand what is required to make competency-based HHR planning effective. They also provide a starting point for discussions which will lead to an integrated and coordinated HHR strategy. The more detailed background papers and guides used to develop this chapter are available on request from the Emergency Management Unit, Ministry of Health and Long-Term Care.
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8.1 Objectives • To describe a competency-based approach to health human resources (HHR) planning.
• To identify the skills and competencies required to provide influenza care.
• To provide tools that planners can use to develop pandemic HHR plans.
• To provide tools that health care providers can use to assess skills.
8.2 Responsibility for HHR Planning The competency-based approach to planning for pandemic influenza may be helpful for stakeholders planning in individual health care organizations, in the local community, within the Local Health Integration Networks (LHINs), and at the provincial level. HHR planning and staffing is usually done organization by organization. During a pandemic, each health care organization will continue to be responsible for managing its staff. However, as part of pandemic preparedness, the ministry recommends that key stakeholders work together at the local, regional and provincial levels to ensure that planning occurs across all care settings including: community and primary health care, emergency departments, acute care, longterm care, and critical care sites. Planning should occur in a bottom up fashion. This means that local planners would estimate the health human resources required to provide influenza care in all settings in their local planning area. They can then coordinate with regional and provincial planners to determine how to make the most effective use of available people and skills. Engaging the workforce leadership (i.e., regulatory colleges, professional
associations, unions) in discussions about the competencies required to deliver care in a pandemic can help establish interdisciplinary teams that can react quickly during a crisis.
8.3 A Competency-based Approach for Planners Competencies are defined as the skills, knowledge and judgment required to deliver a particular health service. A competency-based approach identifies the competencies required and the competencies available to deliver the services that people need during an influenza pandemic. The planning activities involved in this approach include both quantitative and qualitative data collection. Quantitative data would include information on such items as population size, attack rates and the number of providers available. Qualitative information would come from key informant interviews or focus group discussions with workforce leadership on the following:
• Are there non-registered providers (e.g., retirees) in our planning area who could be registered expeditiously?
• How can we get those providers who are in administration and research back into patient care?
• How do we shift part-time workers to full-time workers?
• What are the competencies of these providers?
• What is their level of productivity? This approach is intended to increase the care capacity available for a large number of influenza patients by making strategic use of the competencies of all available health care providers, students, and volunteers. With
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this approach, planners consider the competencies rather than the professions required to meet the needs of the population. This may allow for more staffing options given the range of different professionals who may be able to provide the required competencies during a crisis. For example, if the emergency department (ED) triage nurses are suddenly unavailable due to illness during a pandemic, how would a hospital administrator know what other nurses might have the competencies to provide ED triage? One way could be to have hospital staff complete a skills/ competencies self-assessment survey, which might reveal that several nurses working in other capacities in the hospital have taken nursing triage courses or are military reservists with experience working in combat situations in the triage capacity. Another alternative would be to offer training in triage to other emergency and step down staff before a pandemic begins. One of the goals of a competency-based approach to workforce deployment is to free up those health professionals who are specially trained and competent in influenza care to focus on those patients who are in greatest need. Competencies by Setting Different care settings provide different types and levels of service and, therefore, require different competencies. Different health care providers also have different levels of competencies. Planners use this information to find effective ways to address the “gap” in competencies (i.e., the difference between the competencies required and competencies supplied) by identifying people who have or could be quickly trained to provide those competencies such as: health care providers, students, volunteers and others. During the interpandemic period, planners are
encouraged to engage workforce leaders in conversations to develop the appropriate provider networks and “up-skilling” training programs. In the competency-based approach, planners attempt to answer two key questions:
• What is the spectrum of competencies required to meet the needs of patients in each care setting?
• What competencies can be supplied by providers in that planning area? To answer these questions in terms of influenza care, planners will: estimate the number of influenza patients by care setting (i.e., using sample numbers provided by “FluSurge” or “FluAid”); identify the services provided in those settings and the competencies required to provide those services; and identify the professions who can deliver those competencies. With this information, planners can then think beyond traditional credential-based silos and consider a broader range of staffing options to meet the population’s health needs. Note: this section focuses on HHR planning for influenza care only. Health care settings and regions will also have to plan for the HHR required to maintain other essential health services during an influenza pandemic.
8.4 Influenza Care Competencies To provide care for people with influenza, different health care settings will require different competencies depending on the type of services they provide. See Chapter 8A: Health Human Resources Tools for a comprehensive list of influenza care competencies – that is, the competencies the health care system requires to provide care for people with influenza – organized into the following categories:
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• administrative support • transportation
In order to be useful in teams providing care, staff will need to be able to perform several of the competencies.
• education • infection control • care services. 8.5 Influenza Competencies Required As Figure 8.1 illustrates, the mix and quantity of influenza care competencies (ICCs) an individual health care setting or a geographic area will require during an influenza pandemic will depend on:
Assessment Competencies Many competencies are needed to provide care to influenza patients; however, the most important competencies, and those which will be most difficult to supply, are the competencies to assess patient status, to develop a care plan for the patient, to identify whether additional care is needed, and to determine whether the patient can be discharged from the care site. These competencies are also the most difficult to assess.
• the size and mix of population served in the setting or area (demographics)
• health status, attack rate, mortality, and morbidity (epidemiology of the virus)
Figure 8.1: Competency-Based Health Human Resources Planning Framework
• the type and level of service provided in the care setting or area
• the competencies required to provide that type and level of service. For more detailed information on how to assess these factors, see Key Questions for Planners in a competency-based HHR approach in Chapter 8A: Health Human Resources Planning Tools. Planners would use the information on available competencies to deploy staff to meet needs. If – after redeployment of existing staff – there is still a gap between the competencies required and the competencies available, planners would then look beyond the current workforce (e.g., students, retired health care providers, people with some first aid or other training, volunteers). It is also important to note that the most useful means of extending the human resources available is not by identifying staff with competence for individual acts.
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8.6 Identifying Competencies Available As Figure 8.1 also illustrates, the influenza care competencies available to the setting (i.e., from existing providers) will depend on:
• the number and mix of health care providers in the setting or area
• their productivity – which is a function of the stock of providers and their activity and participation rates (i.e., how many hours they work and how much care they can deliver). To prepare for an influenza pandemic, health care settings and/or local planners need information on the number of health care providers available and their competencies. See Chapter 8A: Health Human Resources Planning Tools for Key Questions for Planner on Provider Supply. The tools chapter also includes a selfassessment tool developed to help health care providers reflect on their own abilities and competencies to provide care during an influenza pandemic. Planners may be able to collaborate with their workforce to use this tool to help quantify the competencies available. To understand the actual amount of influenza care the existing workforce can provide; planners would then have to take into account the number of providers and the hours they work – as well as the potential 20% or higher absenteeism rates that are likely to occur at the peak of the first pandemic wave. When considering the competencies available, health care settings may also contact and include recently retired employees, part-time employees who might be willing to work more hours during a pandemic and students. As part of HHR planning, employers are encouraged to talk
to staff and other health care providers about the province’s pandemic plan and to discuss how health care workers can contribute to both the planning process and pandemic response.
8.7 Health Care Providers’ Role in Identifying Competencies Health care providers and their professional colleges and associations will play a crucial role in optimizing the deployment of the health workforce during a pandemic. Health care providers and their regulatory colleges can assist in identifying competencies, determining the types of care that individuals can safely provide, and ensuring that health care providers do not end up in situations that are beyond their knowledge and skills. To give individual health care providers an opportunity to reflect on their own ability to assist during a pandemic, Ontario has developed a self-assessment tool made up of two major components:
• Part I is an assessment of personal abilities as they relate to influenza care and to the health care provider’s own professional and personal circumstances.
• Part II is an RHPA Controlled Act/ICCs Decision Tree that places ICCs within the regulatory context and provides an accessible overview of certain key questions and consequences in assessing abilities to assist in an influenza pandemic. The self-assessment tool attempts to be as inclusive as possible recognizing that individual circumstances will vary depending upon the profession, the practice setting and the nature of the professional practice of the heath care provider. A resources handbook is available to guide
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health care providers wishing to assist in the pandemic response.
8.8 Matching Competencies Once employers/planners have an understanding of the influenza care competencies required as well as the competencies of existing staff, they will go through a matching process to determine whether they will have the right mix and amount of competencies to meet needs in each setting during a pandemic. Many influenza care competencies (e.g., administrative support) can be provided by a variety of people from volunteers to regulated health professionals; some can only be provided by people with specific training or skills. When matching competencies, planners and health care providers must work within the legislative framework for health care in Ontario: the RHPA specifies a number of controlled acts (or health care procedures) which are authorized ONLY to specific professions (see Chapter 8A: Health Human Resources Planning Tools) – although being in a certain profession doesn’t necessarily mean that an individual has the necessary skill, education or experience to perform the controlled act safely and competently. For example, a physician who has practiced only psychiatry for the last 20 years may not be competent to intubate even though intubation is within the scope of practice of a physician. This reinforces the value of a competency-based rather than credential or profession-based approach to deploying the health workforce during a pandemic. While any controlled act may be delegated by someone authorized to perform that act to another regulated health professional or non-regulated person, the ability to use delegation as a way to provide more care is often limited by profession specific
standards of practice (e.g., a health care worker who feels he or she cannot perform the act safely can refuse to do so) and institutional rules that may prohibit delegation. In addition to the restrictions placed on health care professions by the RHPA, regulatory college regulations, institutional rules, or their own self assessment of their skills, there are other legislative limitations. For example, under Regulation 965 of the Public Hospitals Act, only a physician can order tests and treatment for hospital inpatients and outpatients while Registered Nurses in the Extended Class can only order tests and treatment for outpatients of the hospital. Even when influenza care competencies are not controlled acts, they may require a certain level of education, training and judgement to be done effectively. For example, “assessment” and a number activities associated with assessment – such as taking a pulse, blood pressure measurement, assessing breathing or skin colour – are not controlled acts, but people doing these activities must have the skill to interpret the results. Some activities can only be performed by a person who holds an appropriate registration/license to do so (e.g., registration with the College of Physicians and Surgeons of Ontario). Given these restrictions and limitations, Chapter 8a: Health Human Resources Planning Tools sets out the influenza care competencies that are in the public domain as well as those that require more skills or are controlled acts.
8.9 Structuring Care to Make Effective Use of Provider Competencies Health care settings can structure care in a number of ways that allow them to make
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the most effective use of provider skills. For example, they can:
and decision-makers.
• Support providers are those who can
• use detailed care plans and algorithms –
provide some, but not all, of the technical skills. They are not sufficiently competent to assess the overall status of the patient.
which rely more on set patterns of care rather than the judgement of the health care worker
• have experienced staff supervise less
• Assessment providers may or may not be
experienced staff (i.e., designing care to be delivered in “teams” or “pods”) – which also provides the greatest support to providers working in extended or new roles
able to provide all of the technical skills, but they have the competency to assess the status of the patient, and provide a care plan for some, but perhaps not all, patients. They can recognize when patients need additional care, but do not have the competence to discharge patients from the care setting.
• use a “cascade” system for deploying resources – that is, as resources need to be extended, moving staff whose competencies require the least supplementation to take on new/different roles. For example, the triage role in the emergency department requires the highest level of competence in initial assessment and is usually provided by a subset of emergency nurses. As triage resources become stretched, the setting would first move other emergency nurses into this role, followed by nurses from in-patient units who have assessment/ED technical skill capacity being moved from in-patient units into the ED – who would be replaced in the inpatient units by student/retired nurses.
• differentiate between the competencies required to assess patients and the competence to discharge patients from the particular care site: referring to a “more competent” practitioner provides a safety net. Chapter 8A includes an example of one approach to using competency assessments to create teams of care providers for different care settings. In this framework, providers are generally categorized as support providers, assessment providers,
• Decision-maker providers are those with the competence to assess all patients in the care setting, make final decisions regarding care plans, and discharge patients. This framework also has some relatively specialized functions: telephone triage of patients, emergency department triage of patients, provision of psychosocial support and rehabilitation, and discharge planning
8.10 The Role of Volunteers When planners identify a gap between the influenza care competencies required and those available from existing health care providers, they will have to look beyond their traditional workforce for assistance. Volunteers provided valuable assistance in past pandemics and in other emergency situations. For example, in the 1918 pandemic, a doctor in Ottawa, Ontario, provided a two-day course and trained hundreds of women to help care for people at home. Organizations like the Red Cross and St. John’s Ambulance also provided much needed medical personnel and administrative support. In just the last few years, volunteers played key roles in
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responding to Hurricane Katrina and the tsunami. Past experience offers valuable lessons on how to plan for and use volunteers, including:
Figure 8.2: Steps in Planning for the use of Volunteers during an Influenza Pandemic
• Integrate local volunteer organizations early into the planning process – before a pandemic occurs.
• Develop effective working relationships/partnerships with local chapters rather than national organizations.
• Develop effective communication among volunteer groups, governments, local communities and other stakeholders. Figure 8.2 illustrates the steps in planning for the use of volunteers during an influenza pandemic. Identify Roles for Volunteers
To identify roles for volunteers, health care setting/planners will consider the following questions:
• Which influenza care competencies can be done by volunteers?
• Are there tasks currently performed by health care staff that could be done by volunteers during a pandemic? Based on that assessment, the health care setting can develop job descriptions that will clearly lay out the roles and responsibilities, as well as the knowledge and skills required (see sample in the Chapter 8A.) Recruit and Screen Volunteers Planners may consider recruiting volunteers from a number of sources including:
• the organization’s existing volunteers • organizations who employ people with some health care training or skills (e.g., Red Cross, St. John Ambulance)
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• volunteer centres in the community
• If a volunteer does not have the necessary competencies can training be provided to bring them up to the appropriate level?
• family members of residents (i.e., in long-term care homes)
• high schools, colleges and universities • faith-based organizations. The local pandemic planning committee may consider establishing a central clearinghouse for volunteers that would help recruit, orient and train volunteers as required for all care settings in the community. They may allow for more efficient use of volunteer resources during a pandemic. A central mechanism for recruiting volunteers could also be responsible for screening volunteers. While it is possible to do a detailed screening of volunteers before a pandemic, once an emergency exists, this will be more difficult. Screening will likely consist of an application form (see Tools section) that collects some of the information required to meet legal (e.g., Child and Family Services Act, Safe Schools Act, LongTerm Care Act) and liability requirements, as well as other procedures, such as:
• interviews • medical checks • reference checks • police record checks • specialized testing
• Are there any conditions that will automatically disqualify a volunteer from the position?
• If a volunteer is disqualified for one position, can they be used in another?
• Can your organization’s screening protocols be modified to fit the context of a pandemic?
• Could a third party assist in screening volunteers?
• Who will develop and apply the screening process?
• Will you apply the process to current volunteers and those starting with the organization, or will you apply the process to only episodic volunteers present during the pandemic?
• Can the cost of some screening processes (e.g., a criminal record check be waived during an influenza pandemic)? Orient and Train Volunteers Volunteers will require effective orientation to the health care setting and training for their duties. During a pandemic, orientation programs will be less detailed. They should include:
• orientation/training/probation
• an overview of influenza
• buddy system
• a description of the volunteer position/s
• regular supervision/evaluation • unannounced spot checks. Health care settings would give some thought to how they will manage screening and other volunteer activities during a pandemic. Here are some questions to consider:
– with a written job description
• information volunteers need about the facility, patients and setting
• a volunteer orientation manual (if available). Training may also have to be more focused than in a non-pandemic situation; however, it should include:
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• infection control practices and procedures
volunteers, consider the following:
• How do you currently communicate
• the duties/tasks of the job
with your volunteers? How will you communicate during a pandemic?
• any other information the volunteer requires to perform the task
• How will volunteers provide feedback express concerns during an influenza pandemic?
• supervision • how to cope with any fear, stress or grief associated with their work. Depending on the demands on the health care setting, more experienced volunteers may be responsible for providing the orientation and training for new volunteers. When planning volunteer orientation and training programs, health are settings will consider the following:
• Can existing training programs be modified for use in a pandemic?
• Can volunteers be trained in advance?
• What spiritual/emotional supports are available for volunteers during and post pandemic? Who will provide these supports?
• What volunteer recognition initiatives could be carried out during an influenza pandemic?
• How do you expect to counteract the fear the pandemic will cause? See Chapter 8A: Health Human Resources Planning Tools for a list of Ontario Volunteer Centres.
• Are there third party organizations that could provide some of the necessary training for your volunteers?
• Are there online resources that could be used for training?
• Will training be done before the volunteer starts the position or on the job?
• Can more experienced volunteers provide training/mentoring to incoming volunteers? Retain Volunteers Because of the likely shortage of workers during a pandemic, it will be crucial for health care setting to retain their volunteers. One of the best ways to keep volunteers is to ensure they are kept informed and supported in their roles. If volunteers feel that they are receiving all necessary information, they are less likely to succumb to fear and more likely to stay involved. When developing strategies to retain
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References Buckley J, Morris N, Tomblin Murphy G et al. Health Human Resources Planning for an Influenza Pandemic: A Resource Handbook for Volunteer Utilization. Med-Emerg Inc. Mississauga, Ontario, 2006. Tomblin Murphy G, O’Brien-Pallas L, Birch S. Canadian Nurse Practitioner Initiative: Health Human Resource Planning/Modelling Activities for Primary Health Care Nurse Practitioners. Canadian Nurses Association, Ottawa. 2005. Tomblin Murphy G, Vaughan P, McGeer A et al. Health Human Resources Planning for an Influenza Pandemic: A Resources Handbook for Planners. Med-Emerg Inc. Mississauga, Ontario, 2006. The Regulated Health Professions Act (RHPA). Available at: http://www.e-laws.gov.on.ca/ DBLaws/Statutes/English/91r18_e.htm Alderson D, Tomblin Murphy G, Vaughan P et al. Health Human Resources Planning for an Influenza Pandemic: A Resource Handbook for Health Care Providers. Med-Emerg Inc. Mississauga, Ontario, 2006. Birch S, Kephart G, O’Brien- Pallas L, Tomblin Murphy G et al. Atlantic Health Human Resources Planning Study. Med-Emerg Inc. Mississauga, Ontario, 2006. Tomblin Murphy G, Birch S, Wang S et al. Canadian Nurse Practitioner Initiative: Primary Health Care Nurse Practitioner Projection Model. Med-Emerg Inc. Mississauga, Ontario, 2006. World Health Organization. Epidemic and Pandemic Alert and Response: Current WHO Phase of Pandemic Alert. 2005. Available at: http://www.who.int/csr/disease/ avian_influenza/phase/en)
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8A. Health Human Resources Planning Tools Contents 1. Influenza Care Competencies ........................................................................................................1 2.
Key Questions for Planners............................................................................................................3
3.
List of Controlled Acts (Regulated Health Professions Act) .....................................................6
4.
Influenza Care Competencies Self-Assessment: How Can I Assist In An Influenza Pandemic?.........................................................................7
5.
RHPA Profession / Influenza Care Competencies Matching.................................................23
6.
Sample Framework for Using Competency Assessments to Plan Team-based Care for People with Influenza ................................................................................................................31
7.
Volunteer Position Description Template..................................................................................32
8.
Sample Request for Volunteers ...................................................................................................34
9.
Sample Volunteer Application Form..........................................................................................35
10.
Directory of Ontario Volunteer Centres.....................................................................................36
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Influenza Care Competencies Domain
Competencies
A. Administrative/ Support
a. Management/leadership/innovation: i Ability to respond to crises, develop strategies for response ii Care site management (care clinic, immunization clinic, ED, home care): iii Organization, staffing, response to changing situations for particular setting, iv Assessment of staff competencies, and matching to needs, and v Scheduling and deployment: staff (physician, employees, and volunteers), beds, and sites. vi Succession and contingency planning, and vii Coordination of triage and rationing decisions, ethics. b. Coordination of patient flow: i Answering patient questions, and ii Receiving and directing patients. c. Communication i Coordination with other levels of care, public health ii Internal communication: status of pandemic, changes. d. For hospitals and alternate care sites: i Pharmacy Ii Laboratory service Iii Radiology iv Supplies (clean/sterile, as well as office) v Health records vi Information infrastructure management: telephones, email, hospital information system, surveillance infrastructure vii Food services viii Laundry ix Parking x Security xi Housekeeping xii Disposal of waste (including handling and disposal of biohazardous waste) xiii Facility management (ventilation, creation of isolation space, etc.) xiv Ability to prepare bodies for burial/cremation, and store pending transport.
B. Transportation
a. Patients including assessment and provision of care to patients during transport b. Laboratory specimens c. Waste d. Dangerous goods (e.g., oxygen) e. Staff.
C. Education
a. Ability to educate health care professionals about i Provincial emergency and pandemic preparedness ii Individual preparedness (e.g. wills, stockpiling OTC meds, etc.) iii Influenza and pandemic influenza iv Self screening for influenza illness and for stress/ability to continue working v Assessment, triage, management protocols (patient with and without comorbidities): within healthcare settings, within community/PHC settings (e.g., pharmacy, teletriage, schools) vi Infection control and occupational health and safety. b. Ability to educate the general public about i About influenza including self care ii Pandemic preparedness. c. Ability to respond to questions about influenza and self care (phone, web, in person)
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D. Infection control/occupational health and safety
a. Ability to screen staff for illness. b. Ability to identify staff who through other illness or burn out, need assistance/rest. c Ability to develop surveillance programs i For disease ii For adverse events of immunization and therapy. d. Ability to implement surveillance programs i For disease ii For adverse events of immunization and therapy. e. Ability to monitor workplace and patient safety i Identify hazards/problems ii Provide on-going education and training iii Rectify hazards. f. Provision of support for staff i Psychosocial ii Logistic (food, gas, care for pets, care for family).
E. Care for well persons
a. Immunization i Ability to screen for eligibility for immunization ii Ability to obtain consent for immunization iii Ability to prepare vaccine for injection iv Ability to inject vaccine. b. Prophylaxis i Ability to screen persons for eligibility for antiviral prophylaxis ii Ability to obtain consent for antiviral prophylaxis iii Ability to prescribe antivirals for prevention of influenza iv Ability to dispense antivirals for prevention of influenza (public health or hospital supply).
F. Care for Ill patients
a. Competencies Across Care Settings i Taking a medical history ii Examining the chest iii Performing a complete physical exam iv Interpreting the results of history, physical exam, chest x-ray, laboratory and point of care testing v Prescribing medication vi Triaging patients to appropriate location: in community, to care location; in ED to level of care vii Deciding to refer patient for assessment by staff with greater competency viii Discharging patient home or to another care setting ix Deciding on palliative care/withdrawal of care x Certification of death xi Designing and implementing rehabilitation programs xii Psychosocial support. b. Supports Across Care Settings i Activities of daily living ii Delivery of food etc (community only) iii Care for dependents (community only). c. Technical skills by Care Setting: i Community/PHC: measuring temperature, pulse, blood pressure, taking blood, obtaining NP swabs, other cultures (e.g. skin swabs, urine), 02 sats ii ED/Acute Care/LTC: Community/PHC skills PLUS ECG, Chest x-ray, performing IM injections, starting intravenous lines, maintaining intravenous lines (site and tubing), setting up oxygen for administration; checking oxygen administration sets, administering oral, inhaled, iv and IM medication, suctioning non-intubated and trachea patients, insertion, maintenance of Foley catheters iii Critical Care: ED/Acute Care/LTC skills PLUS intubation, ventilation, central and arterial line insertion and maintenance, administration of medication by continuous infusion, suctioning, ACLS, management of inotropes and vasopressors, management of insulin infusions, management of dialysis.
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Key Questions for Planners in a Competency-based Approach to Health Human Resources Part I Provider Requirements
Key Questions
(i.e., how many providers are required to ensure sufficient ‘flow’ of health care services to meet the needs of the population?) Population Size (demography)
What is the population size of your geographic planning area?
Refers to the population size by age and sex. Reflects the multiple characteristics of individuals in the population that create the demand for curative as well as preventive health services.
What is the population breakdown by age and sex cohorts? What proportion of your population routinely requires care that cannot be provided in your local area (e.g. in tertiary care centers outside of your area)? How geographically dispersed is your population, in particular is your population at high risk of complicated illness, and who may have trouble accessing care? What impact does your geography have on your ability to provide support at home for ill people? Who is responsible for gathering this information? Where would the information be available?
Health Status, Attack Rate, Morbidity and Mortality Rates (epidemiology) Refers to the health status including attack rate by age and sex (i.e., burden of disease). Collect the reportable disease information from the public health unit.
What are the available sources of information in your area concerning up to date information about the likely number of cases of illness and hospitalizations during pandemics of different degrees of severity? How can you use this information for planning purposes? How can you collect actual data during a pandemic to assist in on-going planning? What are the available sources of information in your area concerning up to date information about numbers of cases of reportable diseases? (e.g., pandemic flu)? How would you use this information for planning purposes (i.e., for calculating the attack by age groups or planning areas in your jurisdiction)? Are there geo-mapping resources available to assist in deployment planning? Who would you ask?
Level of Service: Required to cope with the burden of disease and the other health service needs not associated with the influenza pandemic. It is important to consider the distribution of patients by care settings and the associated intensity of care.
Competencies Required Understanding the variety of competencies (knowledge, skills and judgement) that are required to offer the required level of service in each care setting.
What is the expected distribution of patients across care settings (e.g., community clinics/PHC, ED/acute care hospital, ICUs)? What is the most valid way of determining this distribution? How many people will require supportive care at home (e.g. meals, medication delivery)? Who is the designated person responsible for coordinating the organization of health care delivery in each care setting? Who is their back-up should they become ill during the pandemic? Do you know the usual patient volumes by each of these same care settings? What information systems will be required? Who will update them? And how often? Do you have the list of competencies necessary for the care of both the well and the ill in each of the care settings (i.e., community clinics/PHC, ED/acute care hospital/ ICUs)? With the distribution of influenza patients by care setting, and the list of influenza care competencies by the same care settings, does this help you to understand your planning targets?
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Key Questions for Planners in a Competency-based Approach to Health Human Resources Part II Provider Supply
Key Questions
(i.e., how many providers are or will be available to deliver health care services to the population?) Health Care Providers Refers to the total number of health care providers in the jurisdiction. This includes all health care professions and providers who are currently registered with a regulatory college as well as those who are not.
Do you know how many of each health care profession are available in your jurisdiction? Can you get the number of those professionals in your jurisdiction from the respective regulatory colleges? What alternative sources of information could be utilized? How reliable will that information be? How will you update provider workforce information during a pandemic influenza crisis? Do you have the list of health care professions that have been matched with the influenza care competencies? Can the regulatory college(s) expedite registration of retired or inactive staff or IMGs who would be qualified to provide influenza care?
Stock of Providers
How will you engage local provider leadership to assist you in planning for provider stock information? What mechanism will you employ to update information during a crisis? Who will coordinate this? How many providers are training in your area, and in what professions? How many licensed health care providers live or work in your area? Or adjacent areas? How many are retired or working outside their field but are willing and available? What are the influenza care competencies of your local providers? How will you determine this? Have you considered using a provider self-assessment tool?
Refers to the number of registered health care providers available to provide health care services (also includes those who left practice for retirement or other reasons but remain registered)
Whose job will it be to engage providers? Who will be responsible for gathering the self-assessment information? Can you use that information to plan influenza competency training sessions? Who would run these training sessions? Activity Rates Refers to the number of hours spent in the delivery of patient care service (i.e., worked hours).
How will you maintain activity rate information during a pandemic influenza crisis? Who will be responsible for gathering the information? How many of your providers are working full time, part time or casual? Where will you find the information? Have you engaged provider leaders in pandemic planning? Can you assume most providers will work full-time during a pandemic crisis?
Participation Rates Refers to the proportion of the stock involved in the delivery of patient care.
What percentage of your primary health care workforce is involved in direct patient care? What percentage of your ED/acute care hospital workforce is involved in direct patient care? How will you access this information before a pandemic influenza crisis? What alternative sources of information can you employ during a pandemic influenza crisis? Can you use a provider self assessment tool to determine the level of influenza care competencies among those not involved in direct patient care (i.e., those in administration or research)?
Work and Productivity of Providers Refers to the average rate of
How many vaccines can a public health nurse administer, on average per day? How many possible influenza patients can be assessed each hour in a flu
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Provider Supply
Key Questions
(i.e., how many providers are or will be available to deliver health care services to the population?) services per hour of work delivered to people requiring care.
assessment clinic with a particular range of providers? How many people can a family physician assess per day (e.g., 40 per day which is 5 per hour)? How many prescriptions can pharmacist fill per day, in addition to providing communication, education, and advocacy? Who will coordinate human resource scheduling in your area? ICUs? ER/Acute Care Hospitals? Community Clinics? ALC? Homecare? How will you identify and prevent staff burnout? How will you plan for critical skills shortages? How will you identify staff for “up-skilling?” Are there programs, policies or procedures that could be considered and put in place before a pandemic crisis?
Competencies Supplied The variety of competencies that can be supplied by the available stock of providers across care settings. Different health care providers, even within the same profession, will have different levels of competencies.
With the potential stock of providers in your area with the influenza care competencies, and with estimates of productivity of these providers, can you estimate the competencies that could be supplied in your area by care setting? How does this compare with the competencies required in your area by care setting? Give the range of professions that can provide the influenza care competencies (see matching document described below); can you come up with a plan to address the gap in competencies?
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Ontario Health Plan for an Influenza Pandemic August 2008
List of Controlled Acts Under the Regulated Health Professions Act, the following controlled acts can only be performed by members of specific professions. 1.
Communicating to the individual or his or her personal representative a diagnosis identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or his or her personal representative will rely on the diagnosis.
2.
Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
3.
Setting or casting a fracture of a bone or a dislocation of a joint.
4.
Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
5.
Administering a substance by injection or inhalation.
6.
Putting an instrument, hand or finger: beyond the external ear canal, beyond the point in the nasal passages where they normally narrow, beyond the larynx, beyond the opening of the urethra, beyond the labia majora, beyond the anal verge, or into an artificial opening into the body.
7.
Applying or ordering the application of a form of energy prescribed by the regulations under this Act.
8.
Prescribing, dispensing, selling or (1) of the compounding of a drug as defined in subsection 117 Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.
9.
Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
10.
Prescribing a hearing aid for a hearing impaired person.
11.
Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.
12.
Managing labour or conducting the delivery of a baby.
13.
Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Influenza Care Competencies Self-Assessment: How Can I Assist In An Influenza Pandemic? The purpose of this self-assessment tool is to give health care providers an opportunity to reflect on their own abilities and competencies in the context of the required influenza care competencies. This will help health care providers judge how they may be of assistance in an influenza pandemic. The tool is comprised of two major components:
• Part I - a three-part assessment of personal abilities as they relate to the influenza care competencies and professional/personal circumstances.
• Part II - an RHPA Controlled Act/ICCs Decision Tree which place influenza care competencies within the regulatory context and provides an overview of key questions and consequences in assessing abilities to assist in an influenza pandemic. Individual circumstances will vary depending upon a health care provider’s profession, practice setting and the nature of his/her professional practice. The assessment tool attempts to be as inclusive as possible. There are no “right” or “wrong” answers; instead, it provides an opportunity for health care providers to understand the skills and competencies needed during an influenza pandemic and judge how best to be of assistance.
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Professional/Personal Circumstances I
Practice Setting
I have clinical experience in the following practice settings: A. Patient Care I have clinical experience Hospital
I am competent to practice in
Neonatal ICU
Yes
No
Yes
No
Paeds ICU
Yes
No
Yes
No
Adult ICU
Yes
No
Yes
No
Stepdown unit
Yes
No
Yes
No
Ward
Yes
No
Yes
No
Emergency
Yes
No
Yes
No
Rehab
Yes
No
Yes
No
Palliative Care
Yes
No
Yes
No
Out-Patient Clinics
Yes
No
Yes
No
Other
Yes
No
Yes
No
Administration
Yes
No
Yes
No
Chronic care hospital
Yes
No
Yes
No
Residential
Yes
No
Yes
No
Day care
Yes
No
Yes
No
Hospice
Yes
No
Yes
No
Private Office
Yes
No
Yes
No
In Home
Yes
No
Yes
No
Long-Term/Chronic Care
Community Clinic/
B. Other health care settings Public Health
Yes
No
Pharmacy
Yes
No
Laboratory
Yes
No
Rural/Isolated Areas
Yes
No
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
II
Influenza Care Competencies Assessment
Once you’ve identified your practice setting experience, consider the competencies you currently use or previously have used. For example:
•
If those competencies are Administrative/Supportive in nature, consider the competencies in Domains 1, 2 and 4;
•
If those competencies are Education, Infection Prevention or Occupational Health and Safety in nature, consider the competencies in Domains 2, 3 and 4.
•
If those competencies are direct patient care, consider the competencies in Domains 2, 4 and 5.
Alternatively, you might want to consider all the competencies regardless of your practice experience. When you are thinking about the competencies, remember that the RHPA permits delegation of controlled acts. Therefore, think about both what you are able to do, what could be delegated to you during the crisis. Influenza Care Competencies Domain #1: Administrative/Support Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No With a Team
No
A. Administrative/Support a. ability to manage care site (care clinic, immunization clinic, ER, home care…..)
5-10 years ago >10 years ago
Uncertain
Yes No With supervision Yes No
b. Co-ordination of Patient Care (all settings) i. answering patient questions
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No With a Team
No
5-10 years ago >10 years ago
Uncertain
Yes No With supervision Yes No
ii. receiving and directing patients
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
c. Assessing of Staff competencies needs matching
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
d. Scheduling and deployment of staff, beds and sites
Yes
last 2 yrs
By myself
Yes
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No
No
With supervision Yes No e. for hospital alternate care sites (that is, for newly opened sites to care for patients who cannot care for themselves at home, but for whom there is not enough space in hospitals) the following key departments will need to be functional. Think about your ability to contribute to these departments. i. Pharmacy (e.g., compounding and/or dispensing)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
ii. Laboratory services (e.g., processing specimens, maintaining lab equipment, etc.)
Yes
last 6 months
By myself
Yes
No
6m- 2yrs ago
Yes No
No
2-5 years ago
With a Team
Uncertain
5-10 years ago
Yes No
>10 years ago
With supervision Yes No
iii. Radiology (e.g., ordering and/or applying prescribed forms of energy)
Yes
last 6 months
By myself
Yes
No
6m- 2yrs ago
Yes No With a Team
No
2-5 years ago >5 years ago
Uncertain
Yes No With supervision Yes No
iv. Supplies (e.g., clean/sterile, as well as office)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
v. Health records
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
vi. Security
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
With supervision Yes No vii. Food services (consider experience in providing food for large numbers, and knowledge of public health aspects of food preparation)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
viii. Hospital/commercial laundry
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
ix. Healthcare housekeeping
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
x. Ability to prepare bodies for burial/cremation
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
No
5-10 years ago
Yes No With a Team
>10 years ago
Yes No
Uncertain
With supervision Yes No B. Transportation i. Patients
Yes No
last 10 yrs >10 years ago
Do you have appropriate commercial license?
By myself
Yes
Yes No
No
With a Team
Uncertain
Yes
Yes No
No
With supervision Yes No
ii. Laboratory specimens
By myself
Yes
Yes No With a Team
No
5-10 years ago
Do you have appropriate commercial license?
>10 years ago
Yes
Yes No
No
With supervision
Yes
last 2 yrs
No
2-5 years ago
Uncertain
Yes No iii. Biohazardous waste
Yes
last 2 yrs
No
2-5 years ago 5-10 years ago
Chapter #8A: Health Human Resources Tools
Do you have appropriate commercial license?
By myself
Yes
Yes No With a Team
No Uncertain
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
>10 years ago
Yes
Yes No
No
With supervision Yes No
iv. Dangerous goods (e.g. oxygen)
By myself
Yes
Yes No With a Team
No
5-10 years ago
Do you have appropriate commercial license?
>10 years ago
Yes
Yes No With supervision
Yes
last 2 yrs
No
2-5 years ago
No
Uncertain
Yes No
Influenza Care Competencies Domain #2: Education Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
a. Ability to educate health care professionals about i. Provincial emergency outbreak preparedness
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
ii. Influenza and pandemic influenza
Yes
last 6 months
By myself
Yes
No
6m- 2yrs ago
No
2-5 years ago
Yes No With a Team
>5 years ago
Yes No
Uncertain
With supervision Yes No iii. Assessment, triage, management protocols (patient with and without con-morbidities)
Yes
current
By myself
Yes
No
last 6 months
Yes No With a Team
No
6m- 2yrs ago
iv. Infection control and occupational health & safety
Uncertain
5-10 years ago
Yes No With supervision
>10 years ago
Yes No
Yes
current
By myself
Yes
No
last 6 months
No
6m- 2yrs ago
Yes No With a Team
2-5 years ago
Yes No
5-10 years ago
With supervision
>10 years ago
Yes No
2-5 years ago
Chapter #8A: Health Human Resources Tools
Uncertain
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
No
5-10 years ago
Yes No With a Team
>10 years ago
Yes No
b. Ability to educate the general public about i. Ability to educate about influenza, including self-care
Uncertain
With supervision Yes No ii. Ability to respond to questions about influenza and self-care (phone, web, in person)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No With a Team
No
5-10 years ago >10 years ago
Uncertain
Yes No With supervision Yes No
Influenza Care Competencies Domain #3: Infection Control/ occupational health/ surveillance Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
No
5-10 years ago
Yes No With a Team
>10 years ago
Yes No
A. Ability to screen staff for illness. a. Ability to screen staff for illness
Uncertain
With supervision Yes No B. Ability to develop and implement surveillance programme (design data forms/databases, coordinate data collection and submission to MOHLTC) i. For disease
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
ii. For adverse events of immunization and therapy
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
Yes No C. Ability to monitor work place and patient safety related to risks from influenza. 1. Identify hazards/problems (e.g., inappropriate use PPE, inadequately ventilated areas, staff burn out, inadequate screening practice)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
2. Provide on-going education and training
Yes No
last 2 yrs
By myself
Yes
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
3. Rectify hazards
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
No
5-10 years ago
Yes No With a Team
>10 years ago
Yes No
Uncertain
With supervision Yes No
Influenza Care Competencies Domain #4: Care for Well Persons Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No
a. Immunization i. Ability to screen for eligibility for immunization
With supervision Yes No ii. Ability to obtain consent for immunization
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
iii. Ability to dispense vaccine for
Yes
last 2 yrs
Chapter #8A: Health Human Resources Tools
By myself
Yes
8A- 14
Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
injection
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
iv. Ability to inject vaccine
Yes
last 5 yrs
By myself
Yes
No
5-10 years ago
Yes No
No
>10 years ago
With a Team
Uncertain
Yes No With supervision Yes No b. Prophylaxis i. Ability to screen persons for eligibility for antiviral prophylaxis
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
ii. Ability to prescribe antivirals for prevention of influenza
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
iii. Ability to dispense antivirals for prevention of influenza (public health or hospital supply)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
c. Psychosocial support Psychosocial support for staff
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Influenza Care Competencies Domain #5: Care for Ill Patients Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
A. Competencies to care for patients ill with influenza Consider your competence to care for patients with influenza specifically, remembering that care plans will be available, but also that patients may have co-morbidities and complications. i. Taking a medical history
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
Uncertain
>10 years ago ii. Examining the chest
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
Uncertain
>10 years ago iii. Performing a complete medical exam, including ordering of tests
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No In some, but not all care settings Yes No
iv. Interpret results of history, physical exam, chest X-ray, and laboratory tests leading to a diagnosis
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No In some, but not all care settings Yes No
v. Prescribing medication
vi. Triaging patients in the community to care sites
vii. Triaging patients in the emergency department to levels of care
vi. Deciding to refer patient for assessment by staff with greater competency
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
last 2 yrs
By myself
Yes
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
No
5-10 years ago
Yes No With supervision
>10 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
Yes No
Chapter #8A: Health Human Resources Tools
Uncertain
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No In some, but not all care settings Yes No
vii. Discharging patient home or to another care setting
Yes
current
By myself
Yes
No
last 2 yrs
Yes No
No
2-5 years ago
With a Team
Uncertain
5-10 years ago
Yes No
>10 years ago
With supervision Yes No In some, but not all care settings Yes No
viii. Deciding on palliative care/withdrawal of care
Yes
current
No
last 2 yrs 2-5 years ago
ix. Designing and implementing rehabilitation programs
5-10 years ago
By myself
Yes
Yes No
>10 years ago
No
With a Team
Uncertain
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
x. Assistance with activities of daily living, (e.g., feeding, personal hygiene, skin care [prevention of pressure ulcers])
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
B. Support i. Assistance with activities of daily living, (e.g., feeding, personal hygiene, skin care [prevention of pressure ulcers])
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
ii. Community support – shopping delivery of food, medication etc.
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
Uncertain
>10 years ago
Chapter #8A: Health Human Resources Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
iii. Care for dependents (community only)
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
last 10 yrs
By myself
Yes
>10 years ago
Yes No
No
C. Technical Skills I. COMMUNITY/PRIMARY HEALTH CARE i. Measure temperature
Yes No
Uncertain ii. Take pulse
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No Uncertain
iii. Take blood pressure
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No Uncertain
iv. Take venous blood samples
v. Obtain nasal/NP swabs
Yes
current
No
6m- 2yrs ago
2-5 years ago
By myself
Yes
Yes No
No
>5 years ago
Uncertain
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No Uncertain
vi. Obtain throat swabs
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No Uncertain
vii. Obtain other cultures (e.g.,. skin swabs, urine)
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No Uncertain
viii. Order appropriate lab tests
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No With a Team
No
5-10 years ago >10 years ago
Uncertain
Yes No With supervision Yes No
ix. Measure O2 saturation
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No
With supervision
Uncertain
Yes No
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
II. EMERGENCY DEPARTMENT/ACUTE CARE/LONG TERM CARE: Community/Primary Health Care Skills as above, plus: i. Obtain ECG
ii. Order Chest X-rays and CT scans
iii. IM Injections
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
No
5-10 years ago
Yes No With supervision
>10 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
Yes
last 10 yrs
By myself
Yes
No
>10 years ago
Yes No
No
Uncertain
Uncertain iv. Starting intravenous lines
v. Maintain intravenous line
vi. Setting up oxygen
vii. Checking oxygen administration setups
viii. Administer medications by inhalation
Yes
current
By myself
Yes
No
6m- 2yrs ago
Yes No
No
2-5 years ago
With supervision
Uncertain
>5 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
last 2 yrs
By myself
Yes
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No
Yes No
With supervision Yes No ix. Administer medications by injection
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
x. Administer medications orally
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
xi. Administer medications by IV
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With a Team
Uncertain
>10 years ago
Yes No With supervision Yes No
xii. Suctioning non-intubated patients
xiii. Insertion, maintenance of Foley catheters
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
III. CRITICAL CARE: Emergency Department/Acute Care/Long Term Care and Community/Primary Health Care Skills as above, plus: i. Intubation
Yes
current
No
within 3 months 3-6 months ago
2-5 years ago
By myself
Yes
Yes No
>5 years ago
No
With supervision
Uncertain
2-5 years ago
By myself
Yes
Yes No With supervision
No
Yes No
6m-2 years ago ii. Ventilation
Yes
current
No
within 3 months 3-6 months ago
>5 years ago
Uncertain
Yes No
6m-2 years ago iii.(a) Central line insertion
Yes
current
No
within 3 months 3-6 months ago
2-5 years ago >5 years ago
By myself
Yes
Yes No With supervision
No Uncertain
Yes No
6m-2 years ago (b) Central line maintenance
Yes
current
No
within 3 months 3-6 months ago
Chapter #8A: Health Human Resources Tools
2-5 years ago
By myself
Yes
Yes No
>5 years ago
No
With supervision
Uncertain
Yes No
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Ontario Health Plan for an Influenza Pandemic August 2008
Competency Domain
Have I ever done it?
If Yes to Q1, how long ago?
If ‘Yes’ to previous questions, I feel competent to perform those activities:
If ‘No’ to Q1, is the necessary education and/or training available?
Major Competency
Q1
Q2
Q3
Q4
By myself
Yes
Yes No With supervision
No
6m-2 years ago iv.(a) Arterial line insertion
Yes No
current within 3 months 3-6 months ago
2-5 years ago >5 years ago
Uncertain
Yes No
6m-2 years ago (b) Arterial line maintenance
Yes
current
No
within 3 months 3-6 months ago
2-5 years ago >5 years ago
By myself
Yes
Yes No With supervision
No Uncertain
Yes No
6m-2 years ago v. Administration of medication by continuous infusion
Yes No
current within 3 months 3-6 months ago
2-5 years ago
By myself
Yes
Yes No
>5 years ago
No
With supervision
Uncertain
Yes No
6m-2 years ago vi. Suctioning
vii. Advanced Cardiac Life Support ACLS
Yes
last 2 yrs
By myself
Yes
No
2-5 years ago
Yes No
No
5-10 years ago
With supervision
Uncertain
>10 years ago
Yes No
Yes No
current within 3 months 3-6 months ago
2-5 years ago >5 years ago
By myself
Yes
Yes No With supervision
No Uncertain
Yes No
6m-2 years ago viii. Management of inotropes and vasopressors
Yes
current
No
within 3 months 3-6 months ago
2-5 years ago
By myself
Yes
Yes No
>5 years ago
No
With supervision
Uncertain
2-5 years ago
By myself
Yes
Yes No
>5 years ago
No
With supervision
Uncertain
2-5 years ago
By myself
Yes
Yes No
>5 years ago
No
With a Team
Uncertain
Yes No
6m-2 years ago ix. Management of insulin infusions
Yes No
current within 3 months 3-6 months ago
Yes No
6m-2 years ago x. Management of dialysis
Yes
current
No
within 3 months 3-6 months ago 6m-2 years ago
Yes No With supervision Yes No
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Ontario Health Plan for an Influenza Pandemic August 2008
III
Personal Circumstances
Have you given consideration to the following questions: 1.
Do I work in a sector or for an employer that will allow me to be available to assist in a pandemic situation?
2.
Do I require family support because of dependent child or children, spouse or parent(s)?
3.
Do I have plans to care for family members who may become ill during a pandemic?
4.
Does my family have a personal home pandemic plan?
5.
Does my employer offer any family support?
6.
Have I discussed my participation with family members?
7.
Do I have Critical Illness Insurance?
8.
Are my Will and Estate planning arrangements current?
9.
Am I available to travel within the province?
10
How would I be able to travel to and from work? (Car? Public Transit? Air? Train? Bus?)
11.
Do I have language skills, other than English, that would be helpful to health care delivery during an influenza pandemic?
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Ontario Health Plan for an Influenza Pandemic August 2008
RHPA Profession/Influenza Care Competencies Matching
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Ontario Health Plan for an Influenza Pandemic August 2008
The Next Steps As a general rule of thumb, the more “Yes” responses, the greater the ability to lend assistance. For “No” responses, the self-assessment tool prompts you to consider education/training possibilities to update your competency sets. Once you have assessed your abilities and determined how best you can assist during an influenza pandemic, consider what steps you can take to ensure that your assistance will be utilized to the fullest:
• education upgrading? • college/professional association notification? • notify local health human resource planners? For more information regarding Ontario’s Health Pandemic Influenza Plan visit http://www.health.gov.on.ca/english/providers/program/emu/pan_flu/ pan_flu_mn.html For profession-specific planning information, check with your regulatory body and/or professional association. Summary Health care providers are encouraged to talk with their colleagues, employers, regulatory colleges and the volunteer sector about the province’s pandemic planning process and to discuss how they might contribute to both planning and the pandemic response. Providers with influenza care competencies will be in great demand during a pandemic. Providers are therefore encouraged to give thought to their own personal preparation and how they might contribute their skills and competencies to the health care system during a pandemic.
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Ontario Health Plan for an Influenza Pandemic August 2008
RHPA Profession / Influenza Care Competencies Matching Domain
Competencies
Profession
A. Administrative/ Support
a. Management/leadership/innovation:
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
i. Ability to respond to crises, develop strategies for response. b. Care site management (care clinic, immunization clinic, ED, home care): iii Organization, staffing, response to changing situations for particular setting, iv Assessment of staff competencies, and matching to needs, and v Scheduling and deployment: staff (physician, employees, volunteers), beds, and sites vi Succession and contingency planning, and vii Coordination of triage and rationing decisions, ethics. c. Coordination of patient flow: i Answering patient questions, and ii Receiving and directing patients. d. Communication i Coordination with other levels of care, public health ii Internal communication: status of pandemic, changes. e. For hospitals and alternate care sites: i Pharmacy
Public domain activities; not regulated under the RHPA; may require specific education, training and authorization. NOTE: Under the Drug and Pharmacies Regulation Act non-hospital pharmacies must be supervised by a Pharmacist; under that RHPA s.27 (2)8 “supervising the part of a pharmacy were drugs are kept” is a controlled act. NOTE Dispensing and/or compounding must be done by either a Physician or Pharmacist
ii Laboratory service iii Radiology
Public domain activities; not regulated under the RHPA; may require specific education, training and authorization. Will require Medical Laboratory Technologists.
iv Supplies (clean/sterile, as well as office) v Health records vi Information infrastructure management: telephones, email, hospital information system, surveillance infrastructure vii Food services viii Laundry ix Parking x Security xi Housekeeping xii Disposal of waste (including handling and disposal of biohazardous waste) xiii Facility management (ventilation, creation of isolation space, etc.) xiv Ability to prepare bodies for burial/cremation, and store pending transport.
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
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Ontario Health Plan for an Influenza Pandemic August 2008
Domain
Competencies
Profession
B. Transportation
a. Patients including assessment and provision of care to patients during transport b. Laboratory specimens c. Waste
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
d. Dangerous goods (e.g., oxygen) e. Staff.
C. Education
a. Ability to educate health care professionals about i Provincial emergency and pandemic preparedness ii Individual preparedness (e.g., wills, stockpiling OTC meds, etc.) iii Influenza and pandemic influenza iv Self screening for influenza illness and for stress/ability to continue working v Assessment, triage, management protocols (patient with and without co-morbidities): within healthcare settings, within community/PHC settings (e.g., pharmacy, teletriage, schools) vi Infection control and occupational health and safety. b. Ability to educate the general public about
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
i About influenza including self care ii Pandemic preparedness. c. Ability to respond to questions about influenza and self care (phone, web, in person) D. Infection control/occupational health and safety
a. Ability to screen staff for illness b. Ability to identify staff who through other illness or burn out, need assistance/rest c Ability to develop surveillance programs: i For disease ii For adverse events of immunization and therapy. d. Ability to implement surveillance programs:
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
i For disease ii For adverse events of immunization and therapy. e. Ability to monitor workplace and patient safety: i Identify hazards/problems ii Provide on-going education and training iii Rectify hazards. f. Provision of support for staff: i Psychosocial ii Logistic (food, gas, care for pets, care for family). E. Care for well persons
a. Immunization: i Ability to screen for eligibility for immunization ii Ability to obtain consent for immunization
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
iii Ability to prepare vaccine for injection
Physicians, pharmacists
iv Ability to inject vaccine.
Physicians, registered nurses (extended class), dentists. Authorized under order or regulation: registered nurses (general class), registered practical nurses, chiropody and podiatry (injection only into feet), medical radiation
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Ontario Health Plan for an Influenza Pandemic August 2008
Domain
Competencies
Profession technologists, midwives (within scope), respiratory therapists, advanced care paramedics, critical care paramedics.
F. Care for Ill patients
b. Prophylaxis: i Ability to screen persons for eligibility for antiviral prophylaxis ii Ability to obtain consent for antiviral prophylaxis iii Ability to prescribe antivirals for prevention of influenza iv Ability to dispense antivirals for prevention of influenza (public health or hospital supply).
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
a. Competencies Across Care Settings: i Taking a medical history ii Examining the chest iii Performing a complete physical exam
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
Physicians, registered nurses. Physicians, pharmacists.
Physicians, registered nurses (extended class).
iv Interpreting the results of history, physical exam, chest x-ray, laboratory and point of care testing v Prescribing medication
Physicians, registered nurses (extended class), critical care paramedics.
vi Triaging patients to appropriate location: in community, to care location; in ED to level of care vii Deciding to refer patient for assessment by staff with greater competency viii Discharging patient home or to another care setting
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
ix Deciding on palliative care/withdrawal of care.
Physicians, registered nurses (extended class).
xi Designing and implementing rehabilitation programs xii Psychosocial support.
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
b. Supports Across Care Settings: i Activities of daily living ii Delivery of food etc (community only) iii Care for dependents (community only) c. Technical skills by Care Setting: i Community/PHC: measure temperature
Physicians, registered nurses (extended class), dentists (within scope).
Physicians, registered nurses (extended class) – but not from hospital.
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization. Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
take pulse take blood pressure take venous blood samples
Physicians, registered nurses (extended class) Authorized under order or regulation: registered nurses (general class), registered practical nurses, medical laboratory technologists, medical radiation technologists, midwives (within scope), respiratory therapists.
obtain nasal, NP swabs
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization. May be regarded by some as a “controlled act”, especially if the taking of the swab involves going “beyond the point in the nasal passages where they normally narrow”: RHPA, s. 27(2)6.ii.
obtain throat swabs
Public domain activities; Not regulated under the RHPA; may require specific education,
obtain other cultures (e.g., skins swabs, urine)
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Ontario Health Plan for an Influenza Pandemic August 2008
Domain
Competencies
Profession training and authorization.
order appropriate lab tests
Physicians, registered nurses (extended class), dentists (within scope), midwives.
measure O2 saturation.
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
ii ED/Acute Care/LTC: Community/PHC skills PLUS obtain ECG
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
order chest X-rays and CT scans
Physicians, registered nurses (extended class).
IM injections
Physicians, dentists, registered nurses (extended class), dentist Authorized under order or regulation: medical radiation technologists, midwifery (within scope), registered nurses (general class), registered practical nurses, respiratory therapists, advanced care paramedics, critical care paramedics.
starting intravenous line
Physicians, registered nurses (extended class), registered nurses (general class) dentists, midwifery. Authorized under order or regulation: registered practical nurses, respiratory therapists, advanced care paramedics, critical care paramedics.
maintain intravenous line (site and tubing)
Physicians, registered nurses (extended class), registered nurses (general class) dentists, registered midwifes, respiratory therapists. Authorized under order or regulation: registered practical nurses, advanced care paramedics, critical care paramedics.
setting up oxygen
Physicians, dentists, midwifes. Authorized under order or regulation: registered nurses (extended class), registered nurse (general class), registered practical nurses, respiratory therapists, advanced care paramedics, critical care paramedics.
checking oxygen administration set-ups
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization.
administer medications by inhalation
Physicians, Dentists, Registered Nurses (Extended Class), dentists. Authorized under order or regulation: Medical Radiation Technologists, Midwifery (within scope), Registered Nurses (General Class), Registered Practical Nurses, Respiratory Therapists, Advanced Care Paramedics, Critical Care Paramedics.
administer medications by injection
Chapter #8A: Health Human Resources Tools
Physicians, dentists, registered nurses (extended class). Authorized under order or regulation: medical radiation technologists, midwifery (within scope), registered nurses (general class), registered practical nurses, respiratory therapists, advanced care paramedics, critical care paramedics.
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Ontario Health Plan for an Influenza Pandemic August 2008
Domain
Competencies
Profession
administer medications orally
Public domain activities; Not regulated under the RHPA; may require specific education, training and authorization. Presupposes medication has been properly prescribed, compounded and /or dispensed (i.e., controlled acts).
administer medications by IV
Physicians, dentists, registered nurses (extended class). Authorized under order or regulation: medical radiation technologists, midwifery (within scope), registered nurse (general class), registered practical nurses, respiratory therapists, advanced care paramedics, critical care paramedics.
suctioning non-intubated patients
Physicians, registered nurses (extended class), respiratory therapists, physiotherapists, dentists. Authorized under order or regulation: registered nurses (general class), registered practical nurses, advanced care paramedics, critical care paramedics.
insertion, maintenance of Foley catheters
Physicians, Registered Nurses (Extended Class), Dentists, Midwives, (female patients only). Registered Nurses (General Class), Registered Practical Nurses, Critical Care Paramedics.
iii Critical Care: ED/Acute Care/LTC skills PLUS: intubation
Physicians, Registered Nurses (Extended Class), dentists. Authorized under order or regulation: Registered Nurses (General Class), Registered Practical Nurse, Respiratory Therapists, Advanced Care Paramedics, Critical Care Paramedics.
ventilation
Authorized under order or regulation: Respiratory Therapists, Critical Care Paramedic.
central line insertion
Physicians.
central line maintenance
Physicians registered nurses (extended class) nurses. Authorized under order or regulation: registered nurse (general class), registered practical nurse, respiratory therapists, critical care paramedics.
arterial line insertion
Physicians. Authorized under order or regulation: Respiratory Therapists.
arterial line maintenance
Physicians registered nurses (extended class) nurses. Authorized under order or regulation: registered nurse (general class), registered practical nurse, respiratory therapists, critical care paramedics.
administration of medication by continuous infusion
Physicians, midwives.
Chapter #8A: Health Human Resources Tools
Authorized under order or regulation: Registered Nurses (Extended Class) Nurses Registered Nurse (General Class), Registered Practical Nurse, Respiratory Therapists,
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Ontario Health Plan for an Influenza Pandemic August 2008
Domain
Competencies
Profession Advanced Care Paramedics, Critical Care Paramedics.
suctioning
Physician, Registered Nurses (Extended Class), respiratory therapists, dentists, midwives, Physiotherapists (tracheal suctioning). Authorized under order or regulation: Registered Nurses (General Class), Registered Practical Nurses, Advanced Care Paramedics, Critical Care Paramedics.
advanced cardiac life support
Physicians, registered nurses (extended class). Authorized under order or regulation: registered nurses (general class) respiratory therapists, critical care paramedics.
management of inotropes and vasopressors
Physicians, advanced care paramedic, critical care paramedic.
management of insulin infusions
Physicians. Authorized under order or regulation: Registered Nurse (General Class) with ICU/Critical Care experience, Advanced Care Paramedic, Critical Care Paramedic.
management of dialysis
Physicians, registered nurses (extended class). Authorized under order or regulation: registered nurses (general class), registered practical nurses.
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Sample Framework for Using Competency Assessments to Plan Team-based Care for Patients with Influenza Role
Competency
Potential for controlled acts
Activities
Competencies required
None
-Direct patients to “flu” or “non-flu” triage -Exclude visitors
Ability to maintain order
Domain Screener
Support
Ability to use PPE as appropriate Language competencies an asset
-Ensure hand hygiene and PPE use Triage (ED only)
Triage
None, except in crisis, when decision making care withdrawal of care for patients arriving at ED might be made by this role
Triage patients to levels of care, assess CTAS category
ED triage competencies
Tele-triage
Tele-triage
None
Triage patients, provide education
Tele-triage competencies
Support
None
Assists patients in domiciliary care with basic hygiene, activities of daily living Prepare bodies for morgue /funeral home
Physical ability to assist patients
(advanced diagnosis capabilities)
(Telehealth only) ADL support (domiciliary only)
Ability to use PPE Ability to read English Language competencies an asset Ability to assess vital signs an asset
Assistant
Assessment
IM injection, drawing blood, obtain other lab specimens, administer meds, oxygen therapy, iv/Foley catheter insertion and maintenance
Support for assessment – has some or all of technical skills for care, and may be able to take some/all elements of history
As ADL, plus: Some/all of technical skills for nonICU/resuscitate
Assessor
Assessment
As assistant, plus:
Takes history for flu patients, examines chest, assesses patient status within care plan, all technical skills for non-ICU setting Refers on appropriately within care setting
As assistant, but with ability to make diagnosis, order lab tests, recognize impact of modifying factors and comorbidities, determine if patient “fits” in standard treatment algorithms
• dispense meds, • order lab tests • Interpret tests (to some degree). Critical care assessor (ED only)
Assessment
As assessor plus: some/all ICU technical skills
Monitors, assesses patients with compromised hemodynamic/respiratory status in ED
Ability to monitor patients requiring ICU level care in the ED
Primary decisionmaker
Decisionmaker
As assessor, plus For uncomplicated patients with influenza: decide on disposition, prescribe medications, order non-care plan lab tests, change therapy
For uncomplicated flu patients and those in clinic settings, decide on disposition, prescribe medications, order non-care plan lab tests, change therapy
All of assessment competencies (except critical care), plus ability to diagnose, recommend treatment plan, prescribe meds, discharge patient to another location as long as patient has uncomplicated influenza and/or while working with supervision
Secondary decision maker
Decisionmaker
As primary decision-maker, plus: For complicated patients, decide on disposition, prescribe medications, order non-care plan lab tests, change therapy
As decision-maker, but for acute care in-patients, and those in ED with significant comorbidities/complications
All of assessment competencies (except critical care), plus ability to diagnose, recommend treatment plan, prescribe meds for and discharge patient, for patients with complicated influenza
Critical care decision maker (ED only)
Decisionmaker
All technical skills for critical care
Manages/directs management of patients in the ED with compromised hemodynamic and respiratory status
All of other assessment and decision making competencies, plus the ability to diagnose and treat patients requiring ICU level care
Rehab/
Support
None
To direct rehab programs and assess domiciliary patients for suitability for discharge to other care locations/home
Ability to assess ADL capacity and home support Ability to plan and deliver physical rehab
Support
None
To provide psychosocial support for patients and families
Ability to provide psych/social support
discharge planning Psychosocial support
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Volunteer Position Description Template Volunteer Position Description Template
1
Position Title: Location: Purpose: Risk Level: Time Commitment: # Hours: Term: Major Responsibilities:
Reports to: Competencies required:
Orientation/Training Required:
Screening Required:
Supervision and Evaluation:
Benefits: Supporting Policies:
1
This template is based on a compilation of the templates found in: Volunteer Canada (2001) A Matter of Design: Job Design theory and application to the voluntary sector. Available at http://www.volunteer.ca/volunteer/pdf/MatterofDesignEng.pdf p.65. Cooper,Reva (2002) Risk Management by Position Design: A guide for community support organizations in Ontario Volunteer Canada: Ottawa, Ontario. Available at: http://www.volunteer.ca/volunteer/pdf/RiskEng.pdf p.9. Nonprofit Risk Management Center (2001) Staff Screening Tool Kit: Building a Strong Foundation Through Careful Staffing Corporation for National Service: Washington, D.C. Available at: http://www.nationalserviceresources.org/resources/online_pubs/program_management/staff_screening_toolkit. php?search&search_term=toolkit&m=all p.35. Mason Ward, Tarra (2001) Resource Guide: Answers to the most frequently asked questions about volunteerism and the services of Volunteer Victoria Volunteer Victoria: Victoria, British Columbia. Available at: http://www.islandnet.com/~volvic/_pdfs/programs_resguide.pdf p.94.
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Sample Volunteer Job Description Position Title: Primary Screener Location: Entrance to Hospital/Emergency Room Purpose: To direct patients to the appropriate waiting rooms to be triaged Risk Level: Low Time Commitment: # Hours: 8 hour shifts, 7-3, 3-11, 11-7 Term: Duration of the pandemic Major Responsibilities: Greet patients that enter the hospital site Direct patients to the appropriate waiting area Answer general patient questions Instruct patients on the use of basic infection control procedures Reports to: Security Manager Competencies required: Ability to deal with patients in a kind and compassionate manner Ability to deal with patients who will be scared and/or frustrated Ability to communicate basic infection control procedures Ability to respond to basic patient questions Ability to direct patients to waiting rooms based on established medical protocols Orientation/Training Required: Basic orientation to the layout of the hospital so as to be able to instruct patients to required facilities Orientation on the medical directives established Training on the basic infection control procedures Screening Required: Minimal Application through central volunteer staffing organization Reference check if time permits Supervision and Evaluation: This individual will be supervised by the security staff on duty at the hospital site Triage nurses will provide feedback as to the appropriateness of the individuals use of the medical directives and advice concerning which waiting rooms incoming patients should be directed to Benefits: Personal Protective Equipment Access to prophylaxis/antivirals if available Accident/Illness Coverage Supporting Policies: See policies on first assessments of influenza patients See hospital health and safety policy
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Sample Request for Volunteers2 Agency:
How Many Volunteers Needed:
Address:
Work Location:
Contact Person:
Phone #:
Contact Hours:
Ext:
Email:
Title Of Volunteer Position(s) (If Possible Attach Job Descriptions): Description Of Position (Tasks To Be Done):
Other Information: Indicate Who Can Do This Job: Volunteer Ages
Gender
Vehicle Required
Does Your Facility Have:
Child (Up to 12 years)
Male
Wheelchair Access
Youth (13-18 years)
Female
Adult (19-64 years)
Either
License Class____ Background Check Required
Public Transit Access
Senior (65+ years) ICCs The Volunteer Needs To Do This Job:
Training:
Orientation:
Reimbursement For:
Other Benefits:
Indicate Who The Volunteer Will Work With (Complete where applicable): Ages To Work With
People May Have
Relationship
Child (Up to 12 years)
Mental Disability
Group
Youth (13-18 years)
Emotional Disability
Individual
Adult (19-64 years)
Physical Disability
Both
Senior (65+ years)
Influenza
Volunteer Commitment Required (Actual Days/Hours/Duration Of Position):
2
Adapted from Mason Ward, Resource Guide: Answers to the most frequently asked questions about volunteerism and the services of Volunteer Victoria, p.104
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Ontario Health Plan for an Influenza Pandemic August 2008
Sample Volunteer Application Form First Name:
Last Name:
Languages please check fluency : Speak English
French
Please circle Mr. Ms. Write
etc
Both
Specify other
Address: Phone: Emergency Contact Information: Name: Phone number:
Relationship:
E-Mail: What is the best method/time to contact you: Availability: □ Day
□Evening
□Weekends
Length of time available: Do you have any physical or mental conditions or other restrictions that could affect the kind of volunteering service you can provide? Current Job Responsibilities and Hours: How will your volunteer work affect your family and work responsibilities: * In the context of the pandemic you may want to include a question about whether volunteers will require child or elder care in order to lend assistance Previous Work Experience: Special Competencies, Training, and Hobbies: Previous Volunteer Experience: Do you have your own transportation? □Yes Liability insurance? □Yes
□No
□No
A valid driver’s license? □Yes
□No
How did your hear about the volunteer opportunities at our organization? Signature:
Date:
* If you were using a central organization for screening your volunteers, you could ask the volunteers to select which job description they were interested in and which ones they had the competencies for, you could also have the central organization include a competency list based on the job descriptions which potential volunteers could check off. They could then be matched to the appropriate job. * If you were doing the screening yourself, it might be helpful to include a competency checklist based on the necessary competencies of the positions you are hoping to fill. You can then use this to determine which applicant would be appropriate for which position.
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Directory of Ontario Volunteer Centres ON - Central Community Link North Simcoe Volunteer and Information Connection 67 Fourth Street Midland, L4R 3S9 tel: 705-528-6999 fax: 705-528-6990 www.communitylink.ca
[email protected] Volunteer Resource Centre for Durham Region 50 Richmond Street, Suite 116 Oshawa, L1G 7C7 tel: 905-436-2035 fax: 905-571-1460 www.volunteerdurham.org
[email protected] Helpmate Community Information & Volunteer Bureau 1 Atkinson Street, 4th Floor Richmond Hill, L4C 0H5 tel: 905-884-3000 3839 fax: 905-884-4798 www.helpmate.volnetmmp.net
[email protected]
ON - Eastern Volunteer Bureau of Leeds and Grenville 42 George Street P.O. Box 1813 Brockville, K6V 6K8 tel: 613-342-7040 fax: 613-342-7831 www.volunteerleedsgrenville.com
[email protected] Volunteer and Information Kingston 260 Brock Street, Suite 5, 2nd Floor Kingston, K7L 1S4 tel: 613-542-8512 fax: 613-542-8216 www.volunteerkingston.ca
[email protected] Bureau central des Bénévoles de la région de Hawkesbury 331 McGill Street Hawksbury, K6A 1P9 tel: 613-632-6901 fax: 613-632-7581
[email protected] Volunteer Ottawa / Bénévoles Ottawa 402-2197 Riverside Drive Ottawa, K1H 7X3 tel: 613-736-5266 226 fax: 613-736-5262 www.volunteerottawa.ca
[email protected]
ON - Metro-Toronto Information Markham and Volunteer Centre 101 Town Centre Boulevard Markham, L3R 9W3 tel: 905-477-7000 6840 www.city.markham.on.ca/infomark/InfoMarkmain.htm
[email protected]
Chapter #8A: Health Human Resources Tools
Volunteer Centre of Peel 207-160 Traders Boulevard Mississauga, L4Z 3K7 tel: 905-306-0668 fax: 905-306-8221 www.volunteerpeel.com
[email protected] Volunteer Toronto 344 Bloor Street West, Suite 404 Toronto, M5S 3A7 tel: 416-961-6888 fax: 416-961-6859 www.volunteertoronto.on.ca
[email protected]
ON - North Elliot Lake Volunteer Resource Centre 1 Washington Crescent, Suite 108 Elliot Lake, P5A 2W9 tel: 705-848-1337
[email protected] Fort Frances Volunteer Bureau 140 Fourth Street West, Suite 1 Fort Frances, P9A 3B8 tel: 807-274-9555 fax: 807-274-5456
[email protected] Volunteer Centre of the Blue Sky Region 183 First Avenue West North Bay, P1B 3B8 tel: 705-472-0200 22 fax: 705-472-1448 www.volunteernorthbay.on.ca
[email protected] Volunteer Sault Ste. Marie 8 Albert Street East Sault Ste. Marie, P6A 2H6 tel: 705-949-6565 fax: 705-759-5899 www.ssmunitedway.ca
[email protected] Volunteer Sudbury/Bénévolat Sudbury 960 Notre Dame Avenue Sudbury, P3A 2T4 tel: 705-561-8873 fax: 705-560-2767 www.volunteersudbury.com
[email protected] Volunteer Thunder Bay 125 South Syndicate Avenue, Unit 13, Victoriaville Mall Thunder Bay, P7E 6H8 tel: 807-623-8272 225 fax: 807-622-6435 www.volunteerthunderbay.ca
[email protected] Volunteer Timmins 85 Pine Street South, Suite 07, Lower Concourse Timmins, P4N 2K1 tel: 705-264-9765 fax: 705-264-9767 www.volunteertimmins.com
[email protected]
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ON - South-Western Volunteer Halton 860 Harrington Court, Suite 209 Burlington, L7N 3N4 tel: 905-632-1975 fax: 905-632-0778 www.volunteerhalton.ca
[email protected] Volunteer Cambridge 150 Main Street, 2nd Floor Cambridge, N1R 6P9 tel: 519-623-0423 fax: 519-623-9298 www.cvbinfocam.on.ca
[email protected] Volunteer Hamilton 627 Main Street East, Suite 206 Hamilton, L8M 1J5 tel: 905-523-4444 fax: 905-523-7465 www.volunteerhamilton.on.ca
[email protected] Volunteer Centre of Guelph/Wellington 46 Cork Street East, Unit 1 Guelph, N1H 2W8 tel: 866-693-3318 fax: 519-822-1389 www.volunteerguelphwellington.on.ca
[email protected]
Chapter #8A: Health Human Resources Tools
Volunteer Connections 5017 Victoria Avenue Niagara Falls, L2E 4C9 tel: 905-356-6580 fax: 905-356-3522 www.informationniagara.com
[email protected] Volunteer Action Centre of Kitchener-Waterloo and Area 151 Frederick Street, Suite 300 Kitchener, N2H 2M2 tel: 519-742-8610 fax: 519-742-0559 www.volunteerkw.ca
[email protected] United Way of Windsor-Essex County Volunteer Centre 300 Giles Boulevard East, Unit A1 Windsor, N9A 4C4 tel: 519-258-0000 1188 fax: 519-258-2346 www.weareunited.com
[email protected]
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9. Accessing Antiviral Drugs and Vaccine Production facilities have to be ready to manufacture vaccines and drugs; others should be stockpiled and distributed around the country. The Great Influenza, John M. Barry
Antiviral Drugs (i.e., anti-influenza drugs) can be used to treat and prevent influenza, and will be an important disease management strategy during an influenza pandemic – particularly during the early wave(s) when vaccine is not available. We do not yet know how effective antiviral drugs will be against the pandemic strain but, when used to treat seasonal influenza, they have been shown to reduce the length of time people are ill and the risk of complications, hospitalization and death.
• ongoing immunization strategies designed to protect the population from seasonal circulating strains of influenza
• plans to acquire and maintain a supply of antivirals and vaccine
• a consistent, ethical, evidence-based decision-making process for determining who has priority access to antivirals and vaccine when supplies are limited
• an effective system to distribute and administer antivirals and vaccine
Ontario currently has an antiviral stockpile large enough to treat 25% of the population, which is more than the proportion of the population likely to become sick enough during a pandemic to need antiviral treatment.
• a mechanism to monitor antiviral and
This chapter discusses antiviral use in adults; for more information on the use of antivirals with children and pregnant women, see Chapter 18 and 18A.
9.1 Objectives
Vaccine is the most effective means to prevent disease and death from influenza during a pandemic; however, it will take time after the pandemic strain is identified to develop a vaccine so it will likely not be available for the first wave. We do not know how effective the vaccine (once developed) will be against the pandemic strain, but vaccines for seasonal influenza usually prevent illness in 70 to 90% of healthy adults. Comprehensive influenza antiviral and vaccine programs include:
Chapter #9: Antivirals and Vaccine
vaccine uptake and effectiveness, and to monitor any adverse reactions to antivirals and vaccine or resistance to antivirals.
Antiviral Drugs 1. To maintain a secure supply of antiviral drugs large enough to treat 25% of Ontario’s population. 2.
To store, distribute, allocate and administer antiviral drugs efficiently and appropriately.
3.
To monitor the safety and effectiveness of antiviral drugs as well as any development of resistance to antivirals.
Vaccine 1. To provide a secure supply of safe, effective vaccine for all Ontarians as quickly as possible.
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2.
To store, distribute, allocate and administer vaccine supplies efficiently and appropriately.
3.
To monitor the safety and effectiveness of vaccine programs.
9.2 Antiviral Drugs Supply The federal government is responsible for approving and licensing antiviral drugs. At the current time, three antivirals are licensed for use in Canada for prophylaxis and treatment of influenza A infections: amantadine, and oseltamivir (Tamiflu®) zanamivir (Relenza™). The last two are neuraminidase inhibitors. When administered within two days (ideally within 12 to 24 hours) of the onset of illness, both amantadine and neuraminidase inhibitors (e.g., oseltamivir) are effective in reducing length of illness. Neuraminidase inhibitors are effective in reducing influenza complications; however, resistance to amantadine can develop when the drug is used for treatment during annual influenza season. A fourth antiviral, rimantadine is not currently licensed in Canada. Because of amantadine’s side effect profile, dosing requirements and risk of resistance, oseltamivir (Tamiflu®) is the drug of choice for most people during a pandemic. Relenza™ is the recommended treatment for pregnant and lactating women. Clinicians may consider other drugs, based on their clinical expertise and judgment.
appropriate treatment for pregnant and lactating women. Governments are also collaborating to learn more about:
• the impact of antiviral drugs in preventing serious health outcomes during an influenza pandemic
• how to manage the stockpile (i.e., extending the shelf life of antiviral drugs). Antiviral Storage and Distribution To be effective, antiviral treatment must be started within 48 hours of the onset of symptoms, and within 12 to 24 hours to be most effective. To provide timely treatment, Ontario must have an effective system for distributing antiviral drugs. During a pandemic, the Ministry Emergency Operations Centre (MEOC) will be responsible for coordinating the distribution of antivirals to hospitals, long-term care homes, pharmacies, and Flu Centres. The system will address distribution of antivirals to special populations, including those under federal jurisdiction (e.g., armed forces, First Nations, RCMP). Use of Antiviral Drugs For treatment
As of July 2008, a national antiviral stockpile was almost completely in place, large enough to treat those needing care and for early containment.
In the early days of pandemic planning, Ontario developed lists of people who, based on their health status or occupational risk, would be first to receive antiviral drugs to treat influenza. These lists are no longer necessary because the province has stockpiled enough antiviral drugs to treat all Ontarians who are likely to become ill (i.e., 25% of the population).
Ontario has committed to maintaining a stockpile large enough to treat up to 25% of the population. This stockpile is currently in place, and includes a supply of zanamivir to diversify the stockpile and provide
Should a pandemic be severe enough that more than 25% of the population will require treatment, antiviral drugs will be distributed according to the available scientific evidence (e.g., priority may be
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given to those likely to develop complications from influenza) and in accordance with the ethical framework for decision-making described in Chapter 2. During a pandemic, treatment regimens may have to be altered (e.g., higher doses, longer treatment courses) and the timing to start treatment may also change, depending on the epidemiology of the pandemic strain. For prophylaxis
Currently there is no evidence that putting large groups of otherwise healthy Canadians on antiviral drugs in order to prevent influenza (i.e., prophylaxis) will slow or stop the spread of a pandemic; however, prophylaxis with antiviral drugs may play a key role in maintaining critical services (i.e., preventing infection in and providing reassurance to people caring for individuals with influenza as well as workers in critical industries) until a vaccine becomes available. Ontario will develop a provincial policy on the use of antivirals for prophylaxis after consideration of the national policy (currently under development) and in accordance with the ethical framework for decision-making. This will help ensure a consistent approach to using antivirals for prophylaxis across all provinces and territories, which will lead to stronger public confidence and morale. Monitoring Adverse Effects Physicians, pharmacists and consumers will be able to report severe and unusual adverse events to Health Canada through MedEffects.
9.3 Vaccine Immunization Strategies In the fall of 2000, Ontario began offering free annual influenza immunizations to all Ontario residents over the age of six months with no contraindications to influenza
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immunization. The program, known as the Universal Influenza Immunization Program (UIIP), provides approximately five to six million doses of trivalent influenza vaccine a year. Ontario will continue to actively promote annual universal influenza immunization, particularly with groups identified by the National Advisory Committee on Immunization (NACI) as being at high risk of complications from influenza. Annual influenza immunization will reduce the morbidity, mortality and demands on the health care system from seasonal influenza strains. Ontario will also promote pneumococcal vaccination of NACI “high-risk” groups during the interpandemic period to reduce the incidence and severity of secondary bacterial pneumonia in people with influenza. Vaccine Supply The federal government is responsible for pandemic influenza vaccine procurement and supply, including developing the domestic infrastructure, maintaining a standby supply of fertilized hens’ eggs ready to convert into vaccines, phasing in new technologies, and ensuring security of supply (i.e., via a pandemic contract). In case of a pandemic, a domestic supplier guarantees to manufacture at least 8 million doses of monovalent vaccine per month and to provide enough vaccine for all Canadians to receive one dose within four months. In October 2001, Ontario signed a Memorandum of Understanding to participate in the Canadian influenza vaccine procurement and supply process. That agreement runs until March 2011. To immunize the entire province, Ontario would require 25 million monovalent doses (based on two doses per person). The province must be prepared to administer
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one dose per person to the entire population of the province within a month. Access to Vaccine Each year, the National Advisory Committee on Immunization (NACI) makes recommendations (published in the Canada Communicable Disease Report) on priority groups for influenza immunization (i.e., persons who are most at risk for influenza, those who could spread influenza to persons at greatest risk). In the event of a pandemic, the Pandemic Influenza Committee, which includes representation from NACI, will make recommendations to federal/ provincial/ territorial governments on priority groups for immunization based on the epidemiology of the pandemic strain. Ontario’s goal is to obtain enough vaccine for the entire population but, during the early stages of a pandemic, vaccine will be in short supply. In this situation, the province will follow the national recommendations for priority groups for influenza immunization, adapting them as required to meet provincial needs. It will also use the ethical framework (see Chapter 2) to guide the decision-making process. Distribution and Administration Ontario has a vaccine distribution system in place to support its Universal Influenza Immunization Program. A similar system may be used to distribute vaccine during a pandemic, with some changes. During a pandemic, Ontario will use primarily a “Pull” strategy to ensure best use of available resources: influenza vaccine will be sent only to public health units, which will organize mass immunization clinics in various locations in their communities. Other vaccines (e.g., essential immunizations) will continue to be administered through current channels. The province has developed an Emergency Mass Immunization/Prophylaxis Plan that
Chapter #9: Antivirals and Vaccine
will address any issues or gaps in vaccine and antiviral distribution, such as security issues and timely distribution to remote communities (see Chapter 9A: Antivirals and Vaccine Tools). Provincial and local vaccine distribution plans include steps to reach special populations, such as those that fall under federal jurisdiction (e.g., armed forces, First Nations, RCMP) and people who are homeless. Monitoring Adverse Events The MOHLTC collects information on Adverse Events Following Immunization (AEFI) through the integrated Public Health Information System (iPHIS). These reports are then sent to the Public Health Agency of Canada (PHAC) and stored in the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS) database. Through this database, the safety of vaccines in Canada can be monitored. Physicians, pharmacists and consumers are encouraged to report any adverse events related to vaccines. Children’s hospitals in Ontario participate in the Immunization Monitoring Program – Active (IMPACT), which tracks AEFIs, vaccine failures and selected infectious diseases in children.
9.4 Next Steps MOHLTC will:
• work with the Public Health Agency of Canada and other provinces and territories to develop a policy on access to antivirals for prophylaxis
• maintain its antiviral stockpile • establish a storage and distribution system (including distribution routes) for antiviral drugs that will ensure access within 12 to 24 hours in all parts of the province. To promote effective use and management
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of antivirals and vaccine, Ontario will develop the following tools:
• an antiviral comparison chart • an algorithm for antiviral treatment • guidelines for handling and managing antiviral drugs, including dispensing procedures and how to limit wastage
• clinical guidelines for antiviral use and patient care in health care settings
• fact sheets on immunization (i.e., benefits, location of immunization clinics).
Chapter #9: Antivirals and Vaccine
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9A. Antiviral and Vaccine Tools Contents Ontario Emergency Mass Immunization Plan....................................................................................... 1 Staff Functions .......................................................................................................................................... 22 Supply Lists for Pandemic Influenza .................................................................................................... 25 Local Public Health Units ....................................................................................................................... 27 Clinic Process Flow Charts ..................................................................................................................... 28 Immunization Training Manual ............................................................................................................ 31
Ontario Health Plan for an Influenza Pandemic August 2008
Ontario Emergency Mass Immunization/Prophylaxis Plan
I. Background In the event of a health emergency such as a widespread outbreak of an infectious disease, a bioterror incident, or broad exposure to a harmful substance, it may be necessary to rapidly provide vaccines or other prophylactic medications to large numbers of people. While Ontario has a robust infrastructure to support regular immunization programs, such as the annual Universal Influenza Immunization Program, this system as it stands cannot be expected to handle the unique challenges of an emergency mass immunization/prophylaxis campaign. The volume of such a campaign will far outstrip that of a typical immunization campaign, expanding beyond the standard target populations, including potentially the entire population. The speed with which emergency mass immunization/prophylaxis must be implemented is also key, particularly for events in which there is a narrow postexposure window during which prophylaxis is effective. Where a typical immunization campaign may operate for weeks or months, an emergency may require activation and broad coverage within days or hours. Concrete, detailed planning around supplies, logistics, and communication must be put in place prior to an event so that response can be comprehensive and immediate. Safety and security are vital considerations in large-scale emergency campaigns as well, particularly in a context where supplies may be limited and fear and anxiety may be widespread. Immunizing or dispensing to large populations over a short period of time poses specific safety challenges, particularly
Chapter #9A: Antivirals and Vaccine Tools
when administered outside of a standard healthcare setting. Injection and drug safety, safe waste disposal, and monitoring for/responding to adverse events must all be carefully addressed. All emergency mass immunization/prophylaxis campaigns require security measures to address the safety of patients and supplies, site security, and crowd and traffic control. Some emergencies, such as a bioterrorism event, will pose additional security issues, including managing the public perception of threat, the potential or perceived potential for clinic sabotage, and accommodating/facilitating the investigation of the event. This plan is based on a range of sources, including information regarding Ontario’s current immunization programs, a literature review examining best practices in mass immunization and mass prophylaxis, and a review of existing frameworks and plans from the local level and other jurisdictions. II. How to Use This Plan Ontario’s current mass immunization planning focuses to a large extent on the threat of an influenza pandemic. It is assumed, as outlined in the Ontario Health Pandemic Influenza Plan (OHPIP), that a vaccine will not be available until four to six months after the pandemic strain is identified. However, extensive planning for the immunization process should be done before the appearance of the pandemic strain. This plan also contains information on planning for an oral-medication based prophylactic clinic. The potential role of prophylaxis in an influenza pandemic is under discussion at a national level. While a
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provincial stockpile of the antiviral oseltamivir has been established, Ontario is currently planning to use its supply primarily for treatment. Should the national strategy on prophylaxis, currently under development, recommend prophylactic use of this supply, the information in this document can be used to support the implementation of these recommendations. Each section of this plan addresses the general approach and expectations for any emergency mass immunization/prophylaxis campaign, then goes on to indicate any specific strategies and details concerning an influenza pandemic. This plan will be expanded in future iterations to address in more detail disease-specific emergency mass immunization/prophylaxis situations. III. Goals of the Emergency Mass Immunization/Prophylaxis Plan
• To protect Ontarians by providing safe, effective emergency mass immunization/prophylaxis to appropriate groups as quickly as possible.
• To store, distribute, allocate and administer vaccines/prophylaxis supplies securely, efficiently, and appropriately.
• To monitor the safety and effectiveness of the vaccine/prophylaxis campaign. IV. Planning Assumptions This plan assumes that:
• Stockpiles of the vaccines/medications will be available at the provincial level, whether obtained from a national stockpile or purchased provincially.
• Due to the emergency situation, many routine public health activities will be curtailed, freeing up staff to be redeployed in support of an emergency
Chapter #9A: Antivirals and Vaccine Tools
mass immunization/prophylaxis campaign (see chapter 6 for details regarding curtailing services in an influenza pandemic).
• Local public health authorities are the experts on what works in their community. This plan will outline the overall provincial approach, responsibilities and expectations, and will offer guidelines, options, and advice regarding best practices that may be useful at a local level. However, it will be up to local decision-makers to adapt the details of this approach to accommodate their specific needs and opportunities, while still ensuring their accountability for tracking supplies, uptake, and the required data. This planning will be included in their local emergency plans.
• In the event of an emergency, local public health units will participate in local Emergency Operations Centres, employing the Incident Management System.
• In some outbreak control situations, certain medications that would be used for prophylaxis are also used in treatment. In those instances, the distribution process developed for prophylactic medications may be used for centrally-held treatment supplies as well. Treatments for hospitalised patients will be handled through the hospitals. As outlined in section V.2, a limited “Pull”/targeted “Push” strategy can be used for treatment of people who are ill but not hospitalised. Some medications may be able to be provided to health care and other critical service workers through their workplace settings, or dispensed at targeted clinics/settings. This will apply to all medications in limited supply being centrally provided for emergency use. Chapter 11 deals with
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community treatment and assessment centres in an influenza pandemic, which will be the source of antiviral treatment for outpatients in a pandemic. V. Prophylaxis Strategy 1. Triggers and Authority
In some emergency scenarios, mass immunization/prophylaxis is an appropriate first strategy to adopt. In other situations, the recommended initial strategies may be smaller-scale and more targeted, such as ring immunization. Mass prophylaxis is appropriate only if those initial measures are overwhelmed or if, in the case of ring immunization, the ring is broad enough to require mass measures (e.g., an entire community is affected). Clear criteria for the activation of the Emergency Mass Immunization/Prophylaxis Plan should be identified. Local public health units will be informed by provincial public health authorities/Chief Medical Officer of Health if this plan should be activated in an emergency. Local public health units may also choose to use this plan to shape mass immunization planning for events such as meningococcal outbreaks. Provincial guidelines for delegation of authority and medical directives for the appropriate action and medication(s) will be developed and issued. Local medical officers of health can adapt these guidelines for their jurisdictions; however, the content should remain substantially the same to ensure consistency across the province. These directives will include the specific medication, the treatment for an anaphylactic reaction, the specific conditions that must be met and any specific circumstances that must exist before the directives can be implemented. The MOHLTC is working to identify and address any scope of practice issues associated with emergency mass immunization/
Chapter #9A: Antivirals and Vaccine Tools
prophylaxis, including the issuing of medical directives. If the medications being dispensed are not approved in Canada or face other regulatory challenges, they may have to be made available under the Special Access Program, and the approvals and authorities related to that program will have to be accommodated. For pandemic influenza, the immunization clinics will be activated once vaccine is available, but planning for the implementation of this capability should be initiated in phase 5. Activation of any prophylaxis clinics will be dependent on the recommendations developed at the national level. 2. Immunization/ Dispensing of Oral Medication Strategy
In a situation where activation of the Emergency Mass Immunization/ Prophylaxis Plan is required, it is likely that there will be significant public anxiety, a demand for immunization/prophylaxis that outstrips the available supply and pressure on the existing capacity of the system. This requires that accountability for the key functions of secure storage, inventory control and tracking, enforcement of any priority groups, and data collection be clearly assigned and consolidated as much as possible. As outlined in more detail in the remainder of this document, the province is responsible for ensuring that there is a supply of vaccines/medications available at the provincial level, identifying any priority groups for Ontario, making allocation plans based on information gathered at the local level, and for distributing vaccines/medications and any provincially held supplies to a designated location within each health unit jurisdiction. The overall responsibility for secure storage, distribution, tracking, and data collection at the local level, and for the actual
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administration of any vaccine/medication to any priority groups, lies with the local public health units. Emergency mass immunization/prophylaxis may not be available through doctors’ offices as would be possible in a standard immunization campaign, but rather through the mechanisms outlined below. This will reduce the demand on other healthcare settings, increase the efficient use of scarce health care workers and resources, and facilitate a consistent approach. It will also, where relevant, provide central points of access for law enforcement investigations. This does not mean that local public health unit staff alone has to perform every function associated with carrying out an emergency mass immunization/prophylaxis campaign. There are various options that the local public health units could apply within their jurisdictions that take advantage of existing systems, skills, and infrastructure. However, final accountability for the key functions outlined above remains with the local public health units, and this must be accommodated in how these options are selected and implemented. Mass immunization/prophylaxis can be administered with a “Push” or a “Pull” approach. The Push approach brings medications directly to individuals or homes in an affected community. The “Pull” approach requires individuals to leave their homes or workplaces to travel to specially designated centres to receive the medication. Emergency mass immunization/prophylaxis in Ontario will be conducted using a phased process that focuses primarily on a “Pull” approach but also incorporates the option for some limited “Push”. A limited “Push” approach is an option to address certain groups, such as frontline health care workers, where the existing infrastructure of their work places can be used
Chapter #9A: Antivirals and Vaccine Tools
to lessen the burden on public health resources. In the first phase, local public health units may choose to distribute the vaccines/medication for frontline healthcare workers in institutional settings, such as hospitals and long-term care homes, directly to the institutions. They may then be able to use existing skill sets and systems within the institutions to perform functions such as screening and administration/dispensing. Institutions may already have sophisticated systems in place for vaccinating/prophylaxing staff (e.g., through their occupational health departments), and in those cases local public health units need only ensure that priority groups are adhered to and that they can fulfill their own responsibilities regarding overall accountability. For frontline healthcare workers who are in the community rather than an institution, the health unit may also be able to use existing systems and skill sets to support the campaign. However, it may be necessary to shift to a targeted “Pull” strategy where targeted Emergency Mass Immunization/ Prophylaxis Clinics are established in designated community settings such as Community Health Centres (CHCs) or Community Care Access Centers (CCACs), rather than taking place directly within the range of settings where community-based frontline health care providers work. Similar targeted clinics/sites can also be used for other groups such as essential service workers, although the infrastructure support that can be accessed to support public health for these clinics is likely to be minimal (e.g. occupational health nurses). The next phase of an emergency mass immunization/prophylaxis campaign would be broad public clinics. Depending on the situation, these may be conducted once the above phases are completed, simultaneous
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with the above phases, or it may be necessary to quickly administer prophylaxis to health care workers while working to setup broader public clinics. This decision will depend on the availability of vaccine/medication, the existence of any priority groups, and the epidemiology of the situation at hand. The principles and expectations outlined in this plan apply to all phases of an emergency mass immunization/prophylaxis campaign, not only to broad public clinics. Please note that this phased approach is intended to make the best use of limited public health resources at the local level. It is up to local planners to determine, with the leadership of local public health units, the applicability of the various phases to their communities and available resources; for some jurisdictions, the phased approach may not be practical, and they may move immediately to the targeted “Pull” phase. A limited “Push” approach may also be necessary for populations such as residents in Long-Term Care Homes and other institutions, people who are hospitalized, individuals housebound due to disability, prison inmates, the homeless, and populations that fall under federal jurisdictions such as the armed forces, federal prisons, and First Nations. Local pandemic planning groups, with the leadership of public health units, should explore various options to access these populations. Plans should ensure the public health units continue to fulfill their designated responsibilities for distributing and tracking limited vaccine/drug supplies, ensuring consistency in their use, and collecting accurate data. For groups such as the housebound disabled, local public health may be able to work to with their local CCACs to access individuals and administer the vaccine/medications. Further planning will have to be done to identify the best approach
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for individuals who are not tied into the CCAC system. For First Nations issues, coordination should take place through the First Nations and Inuit Health Branch Regional Office. More detail will be added to this plan as protocols are developed, but the current assumption is that, in the event of an influenza pandemic, the federal government will supply antivirals from its stockpile directly to First Nations communities; however provincial and local distribution systems will be used to distribute vaccines. For immunizations that require more than one injection, recipients should either return to the same clinic or be assigned a patient identifier that allows their uptake to be tracked. For prophylaxis requiring a prolonged course of medication, a policy must be put in place regarding whether the full course will be given at the visit to the clinic or whether a portion of the total dose is being given (e.g. the first 10 days of medication), and if so, the process by which people will obtain refills. This decision will have to take into account the availability of medication stockpiles, the potential demand, the logistical demands of a refill process, and the risks of lack of followup and an incomplete course. 3. Priority Groups
While the goal of the Emergency Mass Immunization/Prophylaxis Plan is to protect Ontarians, it will take 4 to 6 months to develop a vaccine and it will take time to produce enough vaccine for everyone in the province. Priority groups will have to be identified to guarantee that the health of the province is protected and critical infrastructure maintained while ensuring efficient use of existing supplies. As outlined in the OHPIP, the Pandemic Influenza Committee (PIC) will make recommendations federally about priority
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groups for vaccines in the event of an influenza pandemic, and these recommendations will be adapted at the provincial level for use in Ontario. Any priority groups for prophylaxis will depend on the recommendations from the national level regarding prophylactic use of antivirals. National recommendations regarding priority groups for prophylaxis in some other health emergencies (e.g. for smallpox) also exist, but when situations arise in which rapid adaptation is needed or national recommendations are not readily available, responsibility for making recommendations regarding priority groups in Ontario lies with the Public Health Division, supported by the Provincial Infectious Disease Advisory Committee (PIDAC). The issue of how to confirm priority group status is one that requires further planning. One possible approach is to request photo ID and some sort of documentation from the worker’s employer (where the priority group is employment-based) as confirmation. VI. Communication 1. Public Communication
Public trust is essential to the success of an emergency mass immunization/prophylaxis campaign. It is necessary both for successful uptake/coverage, and also to maintain an orderly response and avoid panic. Key messages for media lines and messaging regarding the overall provincial approach will be provided by the MOHLTC through resources such as the MOHLTC InfoLine and media line, Telehealth Ontario, the MOHLTC and the Healthy Ontario websites, and through provincial media spokespeople. In addition, the MOHLTC has developed a Crisis and Risk Communications Response Plan to be activated in the event of a pandemic or other health emergency to manage provincial health communications. The local level is
Chapter #9A: Antivirals and Vaccine Tools
responsible for local media spokespeople, and for communicating the details of their campaign to their communities and ensuring that communication is consistent with national and provincial messaging. Information can be shared with communities during the pandemic alert phase to promote awareness of the general kinds of actions that will be taken if emergency mass immunization/prophylaxis is required, including key procedures and protocols, the concept of priority groups, how they will be assigned to clinic areas, and post-clinic responsibilities. It may not be advisable to specify clinic locations pre-event, but a robust system must be in place to quickly and comprehensively publicize the activation of such a campaign and the locations involved. During the campaign it will be necessary to provide information to the public on an ongoing basis regarding the disease itself, priority groups, campaign status, clinic location and hours, etc. There will likely also be media interest Tips for Best Practice: in the status and Complex messages should be success of the delivered repetitively through campaign, multiple channels. including Translation or other language needs for communities should be statistics such as identified and planned for in number of advance. people For individuals staffing phone lines, immunized and prepare basic scripts and FAQ number of sheets. deaths. It is important to make sure that communication is aligned with the phased approach outlined under immunization/dispensing strategy. Communication regarding campaigns within health care institutions and/or other targeted clinics should be aimed primarily at the eligible groups, and times and locations should not be widely publicized. However,
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the province’s approach must remain transparent, and communication with the public regarding the overall response and potentially contentious issues must continue. If changes to protocol or practice are necessary as the situation evolves, and those changes impact the public, it is important to clearly communicate what these changes are and the rationale for making them, in order to avoid the perception of disorganization or arbitrary decision-making and maintain public trust. In an influenza pandemic, where the goal is to keep the well and the ill from mixing as much as possible, it is important in messaging to reinforce who should and who should not be presenting at clinics. The symptoms and durations of symptoms which would render people ineligible should be communicated clearly and repeatedly, as well as the screening process that will be in place at the clinics. The following communication channels may be useful. The capacity of the systems in place to handle a planned campaign should be determined ahead of time by the local authorities.
• Telephone: staffed hotlines, as well as use of “hold messages” and automated voice messaging systems to convey basic information about clinics.
• Websites (ensure that content is updated regularly with new information).
• Media: bought advertisements, media releases/updates, and briefings/news conferences; designated media spokespeople.
• Written communications: information packages in public places and available at the clinics themselves.
• Highway/road message boards, message board in public transit systems. In the event of an influenza pandemic, the
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province is preparing basic information resources such as fact sheets on immunization, vaccines and antivirals, which can be distributed to the public and made available at clinics. The local level will be responsible for augmenting this basic information with the details of their program and any other information relevant to their communities. 2. Health Care Provider Communications
The MOHLTC will ensure that health care workers are provided with accessible, useful and accurate real-time information. Provincial and national recommendations, guidelines and directives will be Tips for Best Practice: communicated Consider naming a dedicated person to monitor/facilitate communications to health care between command in the local workers and Public Health Units and the clinics, stakeholders including dissemination/ by the replacement of updated materials for the protocol binders at the clinics. MOHLTC Also consider having a central through a communications area where protocol number of binders, daily IHNs, and other different resource materials are housed, so mechanisms, that it is easy for staff to review at the start of the clinic/shift and make including the sure they have the appropriate EMU materials at their site. Healthcare Exceptions to standard staff time Provider commitments and other staffing practices may be necessary; it’s Hotline and useful to anticipate, define and website, communicate this clearly to staff and videoconferen labour associations. cing with the Health Care Stakeholder Council, and notices such as daily Important Health Notices and directives distributed through the Communications Mailer. The intent with these directives is to make them as much as possible consistent across health care settings. As discussed in the OHPIP, the MOHLTC has also developed an information cycle which includes a daily public health teleconference. See Chapter 12 for details about influenza
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pandemic communication. Other materials that are being developed specifically for health care workers in the event of an influenza pandemic include:
• an immunization manual • guidelines for antiviral management and handling, including dispensing procedures and limiting wastage
• clinical guidelines for antiviral use and patient care in clinical settings
• medical directive guidelines for dispensing antiviral medications by delegation in health care settings. 3. Intergovernmental and Internal Communications
The complex, challenging nature of an emergency mass immunization/prophylaxis campaign and the speed with which decisions must be made and relayed requires a strong system of communications between federal and provincial authorities, between provincial and local public health authorities, and between local public health authorities and clinic sites. At the federal level, the Public Health Agency of Canada has established a secure website to facilitate pandemic planning and response with the provinces and territories, as well as a federal Crisis and Risk Communications Response Plan. As discussed above, the MOHLTC has developed an information cycle for use during a public health emergency, which will ensure regular and timely updates from the province. Resources that may be of use to stakeholders at various levels (e.g. current guidelines, forms, plans, etc) will be made available through mechanisms such as the Ministry’s website. At the local level, it is important to establish clear channels for communication of command decisions and other important
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information quickly to operations and logistics staff at the clinics and elsewhere, and for feedback from those functions to get back to command. All changes to practices and protocols should be documented and disseminated. It is also important to communicate to staff the level of urgency of the campaign and expectations regarding the kinds of staff responsibilities and time commitments that may be necessary. In addition to the range of clinic communication equipment that is recommended (see section XI, Clinic Operations), cell-phones, pagers and handheld devices may play an important role in internal and intergovernmental communications. VII. Supplies 1. Procurement and Access
Stockpiling of supplies such as vaccines and prophylactic medications is often handled at the federal or provincial level. As outlined in the OHPIP, Canada has a pandemic contract with its domestic manufacturer to supply vaccine. However, a wide range of other supplies is also needed to support mass prophylaxis campaigns, including:
• syringes and/or medication dispensing supplies
• general medical supplies • emergency supplies for adverse events • paper supplies • clinic infrastructure supplies. As part of pandemic planning, the Ministry is stockpiling supplies to support the operation of province-wide mass vaccination clinics, including needles, syringes, sharps containers, and Personal Protective Equipment (PPE). However, local planners should be prepared to address local storage, and local distribution of supplies in their plans.
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Sample lists of suggested supplies for an influenza pandemic are included in Appendix B of this plan. Additional information can be found in the supply and equipment lists in Chapter 10A. 2. Storage and Distribution
The province has established storage capacity for a stockpile of PPE and other clinical supplies and equipment in Ontario, including storage for vaccine/medications. However, storage capacity at the local level must be addressed in local planning. Local public health units should assess their storage needs and potential solutions, and consider designating one secure centralized storage location within their jurisdiction. This location does not have to be within a local public health unit facility. Locations such as hospital pharmacies which have existing security and refrigeration capacity may be the best solution in some areas. Once chosen, this location should be communicated in advance to the MOHLTC. The province will deliver all provincially-held supplies (including vaccines/medications) to this central storage site, and all supplies should be kept at this secure location when not on-site at clinics. Even for clinics operating over more than one day, all supplies that have not been used at a clinic during its operational hours should wherever possible be returned to this location for secure storage during offhours. Where geography does not allow the timely return of supplies to a central location, contingency plans for secure alternate/interim storage must be in place. Storage protocols on-site in clinics during their operational hours must also be developed, and capacity for secure storage is one of the factors that should be considered in selecting a site. (See section VIII.2). Storage locations and protocols should address:
Chapter #9A: Antivirals and Vaccine Tools
• proper conditions to maintain the safety and efficacy of the product (e.g. cold chain requirements)
• inventory management (including monitoring of expiry dates where relevant) and restocking
• security of supplies, particularly where shortages or potential tampering is an issue, including access and requisition authority
• contingency planning for cases where the event takes place during a routine immunization campaign and existing refrigerated storage may already be at capacity. Given the need for rapid distribution, there must be measures in place to ensure the safe, secure transportation of the planned allocations. The Ontario Government Pharmaceutical and Medical Supply Services Tips for Best Practice Storage: Consider storing supplies as pre-packaged “packs” or “bundles” (e.g. “Clinic in a box”) for ease of setup and assurance of appropriate supplies in appropriate amounts to maintain safe practices. Distribution: Form a dedicated supply and transportation team, particularly at the local level where goods may be converging from a number of sources, potentially being repackaged, and transported to different clinic locations. Develop a regular requisition and stocking procedure at the local level for the clinic sites (e.g. requisition slips to be submitted by each clinic at the end of each day to the Health Unit) along with the capacity for urgent delivery when needed. As part of local mass emergency prophylaxis planning, establish communication channels with local health care facilities to ensure a rapid response to requests for resources such as antivirals during an emergency. Establish protocols ahead of time for issues such as where deliveries should arrive, who can sign for deliveries, and the necessary security precautions.
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has a fleet of trucks which routinely deliver large volumes of vaccine during routine immunization campaigns. Once the province has delivered supplies to the designated local storage location, the local public Tips for Best Practice health units are In addition to security at the clinics themselves, security staff may be responsible for needed at other sites that the public coordinating the associates with the campaign, such transportation of as the Local Public Health Unit supplies and offices or communications centre. equipment to Have protocols and contingency plans in place to accommodate and from the illness and absenteeism. clinics within their jurisdiction and, in cases where the medication is also being used for treatment of the ill, to hospitals and other institutions. Transportation of supplies should address:
• Vehicles: can public/government vehicles be used or will rentals be required? Are public/private partnerships an option, particularly if refrigerated trucks are needed? Can Federal vehicles, including planes, be used at provincial/local levels?
• Planning for safe secure supply routes at all levels, and coordination between levels.
• How to quickly access remote communities.
• Liaison with law enforcement or other groups needed to ensure security.
• Staffing issues: is special licensing (e.g. trucks or buses, transport of dangerous goods) required?
• Safety issues (e.g. biohazards). During an influenza pandemic, the MOHLTC Ministry Emergency Operations Centre (MEOC) will coordinate through the OGPMSS the distribution of antivirals and vaccines across the province to local public health
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units. The manufacturers of the influenza vaccine have contracted to deliver to a number of sites within Ontario, and discussions are underway to identify these sites. Additional work on an operational protocol for distribution is being done at the provincial level, and will be communicated to the local level once it has been completed. VIII.
Vaccination/ Dispensing of Oral Medications
1. Determining Resource Needs
At the local level, planners should determine the number of clinics, duration / hours of operation for clinics, and clinic staff required to cover their population within the expected timeframes for the given situation. Staff requirements may be based on the models outlined in the Clinic Operations Section, and should address number of staff per site per shift and planned number of shifts per day, which may depend on the nature of the emergency. It is estimated that one nurse can immunize 20 adults or adolescents in an hour, or 15 children, but this will depend to some extent on how the staff functions within the clinic will be assigned (e.g., whether nurses are also performing the medical assessment, or whether immunization assistants are available). Dispensing time for other prophylactic medications (e.g. Tamiflu®) will depend on the complexity of the dispensing process. Local public health units should determine as much as possible in advance ways to supplement their existing staff resources, including volunteers, private agencies or other health care organisations in the region, and charitable agencies such as Red Cross. Chapter 8 provides a discussion of and tools for competency-based health human resources planning in a pandemic context. This may shape an approach to staffing clinics which varies from that of standard immunization clinics. It will allow additional support to be
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provided through regulated health professions with relevant skills for functions such as administering injections within the clinics, so that nursing staff can be concentrated in those functions where their particular skills are most needed. If an emergency mass immunization/prophylaxis campaign must be conducted during the time that a routine immunization campaign is taking place and resources are at full capacity, local public health units will have to make decisions regarding their priorities, the possible need to scale back their activities, and the best ways to implement scale-back to free up the necessary resources. The province will be providing guidance to aid the local level in making decisions regarding priority activities and resource reallocation. Populations may be assigned to various clinic sites based on priority status, their postal code, alphabetically, according to available translators or other language resources on site, or other options specific to the nature of the community. Local planners can make their decisions based on the population density, demographics and other characteristics of their community. The system by which people have been assigned must be clearly explained in communication materials, and policies must be in place to address people who present at clinics other than they were assigned to, including dispute resolution. It is also recommended that local planners in neighbouring communities work closely together in making these decisions. 2. Site Selection
Locations should be selected at the local level with the following considerations in mind:
• local population density and pattern • potential supply routes
• accessible by public transit in urban centres; by car in rural and suburban areas
• availability of sufficient parking • availability/accessibility during evenings and weekends. Specific facilities can be selected considering the following:
• familiarity to the community • size/space requirements for floor plan/local population, including:
• space for internal storage and a “dispensary” or area to reconstitute/draw-up vaccine
Tips for Best Practice Involve appropriate authorities (e.g. school board, Parks and Recreation) early in the planning process regarding potential sites, and resolve issues regarding leases/liability beforehand. Back-up generator capacity is best, but if this is unavailable have extra coolers, frozen ice-packs, and temperature monitors on hand to maintain and confirm cold chain in case of power outage. Keep extra batteries/chargers on hand for cellphones and pagers.
• area separate from the dispensing/administration areas to care for those suffering faints or adverse events
• space for removal and temporary storage of medical waste
• ease of set-up • accessibility for people with disabilities, seniors, and strollers
• secure and accessible area for supply delivery
• the special needs of any populations (e.g., Mennonite populations might need hitching posts for horses, or some
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ethnocultural groups may have higher needs for privacy if the immunization will involve removing any clothing or if gender sensitivity is an issue)
• interior or sheltered areas for line-ups in the event of unfavourable weather conditions
• good lighting, ventilation, and comfortable temperature (i.e. appropriate temperature control according to season)
• facilities for controlled storage of medications/vaccines, including electrical outlets for externally powered cold storage containers,
• electrical system capable of supporting multiple electrical and electronic appliances
• backup power generation capacity/fuel delivery capacity (important particularly in the event of bioterrorism)
• security issues, including: • capacity for both an outer and an inner perimeter that can prevent wholesale movement of crowds into dispensing area
• separate but limited number of entry and exit points, capable of being controlled for security
• security of storage and “dispensary”/reconstitution/draw-up during operational hours
• on-site potable water supply and food storage/preparation capacity
• communications equipment available onsite (if these cannot be available already at the site, they will have to be planned for in supplies)
• land-line capability • Cellular, radio, satellite communications
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• audio-visual equipment if needed for pre-recorded briefings. 3. Protocols
Activities should be protocol-driven to the greatest possible extent in order to ensure maximum efficiency and consistency. It should be noted that the province has adopted and is rolling out the Incident Management System (IMS) as its emergency response protocol. The system is simple in nature and can be applied to any organization, standardizing contact information across organizations, making communication and cooperation among the groups easier, and enhancing interoperability between organizations and levels. Local public health units should adopt this structure for their own Tips for Best Practice Have binders/folders for all staff positions available on-site at the clinics with clinic protocols, staff position job action sheets, information and fact sheets, etc. Assign a clear responsibility for replacing updated protocols and information within these binders. Protocols can be crafted specifically to address whether the prophylaxis being administered is a vaccine or other drug that might require a longer course or more detailed pharmacological information/dispensing advice.
coordinating committees or other central authority charged with planning and running their emergency mass immunization/prophylaxis campaign. Examples of specific protocols which should be developed at the local level for clinics include:
• Clinic set-up, including basic floor plans and station-to-station patient flow options. These can be adapted to reflect local situations, but optimally all clinics in a community should share the same basic layout to ensure interoperability of staff and briefing materials.
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• Staff roles and functions. • Dispute resolution mechanisms and policies.
• Responding to and reporting adverse events. Some of these protocols are addressed in more detail in the Clinic Operations Section 4. Support Services
Necessary support services will include food preparation for staff and the public, toilet facilities for both staff and public, potentially child-care, custodial services, and sharps disposal. Toilet facilities must also be Tips for Best Practice considered for the Food and other support services that will be public outside of the available to the public clinic perimeter. should be communicated Measures to ensure when publicizing the security and traffic clinics so that people can plan accordingly. control will also be required. 5. Transportation
Distribution has already been discussed, but other kinds of transportation are also a vital part of clinic functioning:
• If transportation is a challenge in a local community, clinics are operating offhours when public transit is not available, or there are populations that are not eligible for a “Push” approach but may have difficulty accessing centres, arrangements may have to be made for mass transportation such as buses or shuttles.
• Transportation of staff as well as supplies to the clinic site will have to be planned, particularly for off-hour clinics.
• Transportation protocols and routes to health care facilities in the event of serious adverse reactions or patients
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presenting with serious illness should be established. 6. Serious Illness and Adverse Events
Some adverse events are inevitable in any immunization/ prophylaxis campaign, despite screening measures. In addition, initial screening may identify individuals presenting who are already seriously ill, whether due to the event or from an unrelated illness. In order to respond to these quickly and effectively, plans should include:
• Clear case definitions and protocols for initial screening out of seriously ill recipients, based on case definitions and medical directives provided by the province.
• A post-immunization waiting area, where people can wait for 15 minutes to ensure that there are no acute adverse reactions.
• Trained staff able to monitor recipients in the waiting area for, and respond to, acute adverse reactions.
• Emergency kits including supplies such as epinephrine and other emergency medical supplies.
• Arrangements with acute care facilities to accept cases, transportation protocols for people who require transportation to an emergency department, and communication protocols to inform acute care facilities when cases are en route. While some adverse events will be acute and immediate and will be recorded and treated at the clinic site, protocols for monitoring for and responding to not only acute but delayed adverse reactions must also be established, as well as public communication plans for information about adverse events. This is essential for patient safety and evaluation of the campaign, and to maintain
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public trust. Large-scale campaigns can potentially lead to a public perception of increased risk of adverse events, due to the large number of people receiving the medications and the greater visibility of the usual proportion of adverse events. A good monitoring system allows accurate up-to-date information to be shared with the public to counter rumours or perceived threats. For vaccines, the federal government maintains the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS), and acute flaccid paralysis is monitored by the Canadian Paediatric Surveillance Program (CPSP). In Ontario, certain adverse events following immunization are reportable under the HPPA, and systems are in place to monitor adverse events, but for an emergency mass immunization/prophylaxis situation rapid reporting mechanisms and channels must be put in place. For medications such as antivirals, adverse events will be reported through MedEffects and IMPACT (paediatric). Factors to consider/include:
• Case definitions. • Rapid reporting channels. • For delayed adverse events following immunization (AEFI) – what and how to report.
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• Estimate expected rates of adverse events; use as baseline for actual comparison of actual rates. IX. Documentation A variety of Tips for Best Practice documentation Wherever possible forms needs must be should be in check-box considered. The lists format, pre-populated, or populated using expedited below attempt to be measures (e.g. stickers for comprehensive: not vaccine lot numbers) in order all documents may to save time on paperwork. be necessary for all campaigns. If computer resources are available, data should be entered on each vaccine recipient in “real time” during registration and at appropriate points throughout the immunization process. In the ideal scenario, all personal electronic health record documents will be printed on-site for each vaccine recipient. However, paper copies of all documents must be available in sufficient quantities so that clinic operations can continue if the computer system fails. Whether during the clinic or later, electronic entry of critical data will be necessary. For pandemic influenza, the province is developing consent form guidelines for immunization, guidelines for antiviral management and handling including procedures for dispensing and limiting wastage, and antiviral/vaccine monitoring and tracking forms. IT support for documentation during an influenza pandemic is being discussed at the provincial level.
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1. Documentation: Individual Recipient: Document
Information Collected
Function
Medical Contraindications
Used as preliminary screening tool; persons with potential risk routed for in-depth health screening or priority immunization
For Health Unit
Screening Tool
Registration/Clinic Form
Epidemiological Risk Status Priority Grouping Name, Address, Age/DOB, M/F, any priority group, unique identifier, vaccine given, lot number and dose, immunization site, drug distributed, dose, amount, date Consent: Verbal Yes/No: Have you read?
Official clinic medical record
Do you understand? Adverse Events Report
Name, Address, M/F, date, lot number, reaction, follow -up
Documentation of adverse events for Adverse Events Following Immunization (AEFI) notification
Name, address, age/DOB, M/F, lot number, date, list of contraindications, list of symptoms Clinic staff signature/ stamp
Information entered on card; recipient receives/keeps card to verify receipt
Who/where to call if reaction
Recipients take home, record (where relevant) course of medication, monitor for predetermined length of time for any symptoms they may have
For Recipient Information on a card or sheet of paper: • Vaccine/Medication Information Statement • Immunization/ dispensary Card • Instructions on postclinic responsibilities such as how to care for the vaccination site, where/when to get second dose if required
2. Documentation: Clinic Activities and Operations: Document
Type of Information
Daily Vaccine/Medication Tracking Record
• • • • • • •
Beginning Inventory Doses received Doses Administered/dispensed Ending Inventory Doses Wasted Disposition of Ending Inventory Signature of clinic official
Documents where, when and how vaccine was used A roll-up of this information should be provided by each public health unit to the MOHLTC Emergency Management Unit by 2000 hrs each day
Staffing Assignment Sheet
• • • •
Date of Clinic Clinic Roles Individuals Assigned Responsibilities of Staff Function
Records staffing assignments
Job Action Sheets
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Function
Defines roles
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X. Training 1. Staff Training
As with any emergency response plan, staff training is key to the successful implementation of the plan. The province has developed some materials which will support staff training, such as an immunization manual. Other issues that must be addressed in training staff are:
• Staff must be trained regarding the appropriate infection control guidelines, including appropriate PPE.
• Pre-event training for staff should address how to ensure safe dispensing/sterile technique/injection safety in the fast and high-volume context of an emergency mass campaign.
• Staff must be well-versed in the command structure and staff roles, particularly if use of redeployed staff is anticipated.
• Training must address the rapid set-up of the clinic in potential locations.
• Staff must be trained to recognise and respond to adverse events.
• A process must be developed for rapid orientation of staff when the plan is activated, including review of relevant medical directives, infection prevention and control guidelines, informed consent, reconstitution techniques and dosage issues. 2. Exercising the Plan
Regular exercising of the plan enhances staff understanding of their roles, and facilitates identification of weaknesses and the evolution of the plan itself. Drills and exercises must be conducted often enough for various players to be familiar with their roles and for the plan to be kept up to date
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in the current planning context. An evaluation component must be built into any exercise so that lessons learned during drills and during actual activation can be incorporated. XI. Clinic Operations 1. Occupational Health and Safety
Legislation such as the Occupational Health and Safety Act (OHSA) and the Workers Safety and Insurance Act (WSIA) establish general obligations of employers to protect their employees from harm. Ontario Regulation 67/93 (Health Care and Residential Facilities) under the OHSA establishes a range of obligations for health care employers. These include: consulting the Joint Health and Safety Committee or health and safety representative when developing and reviewing programs, policies and training; establishing infection control procedures including handling of sharp objects and waste; and providing personal protective equipment (PPE) and setting expectations regarding the PPE staff are required to wear. In addition to the standard measures taken by employers to fulfill these responsibilities, an emergency mass immunization/prophylaxis campaign can pose a number of unique challenges to the provision of a healthy workplace, and planning must address this. Clinics should ensure that their staff wears the PPE necessary for the pathogen and the process in question. The province will provide appropriate guidance and direction for PPE selection, and where relevant and necessary, may also provide information regarding protective practices or changes in protective practices. The volume and speed of the campaign will mean that staff fatigue and stress will be an issue, and maintaining safe practices in this
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context should be addressed in training. In large locations, noise may be an issue and add to staff stress and fatigue. In addition, clear protocols must be in place to address incidents such as needle-stick and other injuries to staff, and to ensure adequate linkage to Worker’s Safety and Insurance Board (WSIB). OHPIP Chapter 7 Occupational Health and Safety and Infection Prevention and Control addresses occupational health and infection prevention and control measures during an influenza pandemic in further detail, including recommendations for appropriate PPE. 2. Injection Clinic: Clinic Process
The following outlines the necessary functions that make up clinic operations for an emergency mass immunization clinic. These functions will remain essentially the same across clinics, but depending on clinic size and staff resources, how these functions will be apportioned to staff positions may vary. As previously discussed, the approach to staffing Emergency Mass Immunization/Prophylaxis Clinics during an influenza pandemic may vary from that of standard immunization clinics, and involve a wider range of staff, concentrating nursing staff in those functions where their particular skills are most needed. Step 1: Injection Clinic: Screening, Registration and Briefing
Upon arrival, recipients are directed to the screening and registration area by security personnel handling outside traffic flow and parking. In situations such as an influenza pandemic, where mixing the well and ill is discouraged, screening should be performed proactively, with staff actively performing activities such as febrile screening (or screening for other relevant symptoms)
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before the clinic entrance, including line-ups if line-ups are anticipated. In situations where mixing the well and ill is not an issue, screening can be performed as part of the registration process. Persons exhibiting signs of illness should be triaged to a separate room for more in-depth evaluation with a medical professional (see step 1.5). The screening protocol for this will be based on case definitions, medical directives provided by the province, and standard medical practice. While communications materials should have included information about eligibility and symptoms, it is recommended that visible signage should also be posted identifying the symptoms which may result in ineligibility or require more in-depth evaluation. At the clinic entrance, recipients will be met by greeters and directed to the registration stage. Registration staff will collect data, confirm eligibility, and provide the necessary paperwork and briefing information. Depending on clinic capacity, briefing can be completed individually or on a group basis, and can consist of written materials, briefing by staff or pre-recorded presentations on video if facilities are available. This may require translators and translated materials to reflect the local population. Issues to be addressed include:
• information about the vaccine risks and benefits
• contraindications • what to expect during the administration process
• signs of complications and immediate reporting instructions
• any other important details (such as successful take in case of smallpox)
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• information on completing the registration material and consent forms. A number can be assigned to recipients for traffic control. Following the briefing, time is allowed for recipients to complete the required paperwork (including consent forms) and ask questions. Separate areas may be set aside for orientation, or orientation locations can also serve as holding locations. Step 1.1: Injection Clinic: In-Depth Health Evaluation
If flagged during the screening process (or later during Step 2, the health assessment), recipients may be routed for more in-depth health evaluation of possible illness or contraindications to confirm eligibility or determine appropriate next steps. Depending on the emergency, recipients may be required to wear surgical masks in this area and, if routed back for immunization, throughout the immunization process. Following the health evaluation, patients may be routed:
• back into the immunization process (with or without surgical masks)
• to appropriate level of medical care, e.g. acute-care facility
• home. Step 2: Injection Clinic: Health Assessment
After paperwork is completed, vaccine recipients are routed to the health assessment stage. At this point the staff performing this function will:
• discuss possible contraindications • review common reactions to the vaccine with each vaccine recipient
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• confirm that no current illness requiring more in-depth medical evaluation is present
• ensure consent form is signed. After this assessment, recipients may be routed either back for more in-depth medical evaluation (see Step 1.5), or forward to Step 3. Step 3: Injection Clinic: Vaccination
After assessment, vaccine recipients with no medical contraindications are ready to receive the immunization. Recipients are prepared for immunization (their upper arm is exposed and cleansed if necessary). Then the vaccine is administered, the necessary follow-up Tips for Best Practice The need for an appropriate level of security should influence which staff are operating as screeners/registration staff; for instance fire-fighters or others in uniform may be placed at these stations to help reinforce the authority of screeners. To facilitate efficient traffic flow within the clinic: Ensure that clear signage and direction is posted throughout the clinic, including large outdoor signage to direct ambulances or emergency vehicles if needed. Develop a system to signal when immunization/ dispensing stations can accept more recipients and when providers are away from their stations; flags or colour-coded cards may be used. Design your floor plan to avoid areas where lines merge and cause backups and queues; where queues are inevitable/anticipated, make sure there is room to accommodate them. Make sure that your protocols for handling conflict resolution or individuals requiring special assistance include measures to remove these potential obstacles from the main flow of patients in order to minimize bottlenecks. Pre-designate any ways that station scripts and protocols can be shortened if bottlenecks start to occur and need to be cleared (e.g. portions of briefing that can be eliminated or provided in alternate ways).
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information given (including a record of their immunization and information regarding what complications to watch out for and who to contact if complications occur), and the necessary documentation is completed and collected. The collection of completed forms from the immunization stations is a staff function that must be assigned. Following immunization, all individuals are required to stay at the clinic for 15 minutes, with personnel present to monitor for any complications that require immediate attention. Step 4: Injection Clinic: Exit
After the 15 minute monitoring period is over, recipients will be informed that they are finished with the process and routed to the exit. 3. Oral Medication-Based Clinic: Clinic Process
The following outlines the necessary functions that make up clinic operations for an oral medication-based Emergency Mass Immunization/Prophylaxis Clinic. Many of the phases and function in these clinics will be similar to an injection clinic, differing most significantly at the dispensing stage, but the process is laid out in its entirety here for ease of reference. The functions outlined here will remain essentially the same across clinics, but depending on clinic size and staff resources, how these functions will be apportioned to staff positions may vary. As previously discussed, the approach to staffing Emergency Mass Immunization/ Prophylaxis Clinics during an influenza pandemic may vary from that of standard immunization/prophylaxis clinics, and involve a wider range of staff, concentrating nursing staff in those functions where their particular skills are most needed. Step 1: Oral medication-Based Clinic:
Chapter #9A: Antivirals and Vaccine Tools
Screening, Registration and Briefing
Upon arrival, recipients are directed to the screening and registration area by security personnel handling outside traffic flow and parking. In situations where mixing the well and ill is discouraged, screening should be performed proactively, with staff actively performing activities such as febrile screening (or screening for other relevant symptoms) before the clinic entrance, including line-ups if line-ups are anticipated. In situations where mixing the well and ill is not an issue, screening can be performed as part of the registration process. Persons exhibiting signs of illness should be triaged to a separate room for more in-depth evaluation with a medical professional (see step 1.5). The screening protocol for this will be based on case definitions, medical directives provided by the province, and standard medical practice. While communications materials should have included information about eligibility and symptoms, it is recommended that visible signage should also be posted identifying the symptoms that may result in ineligibility or require more in-depth evaluation. At the clinic entrance, recipients will be met by greeters and directed to the registration stage. Registration staff will collect data, confirm eligibility, and provide the necessary paperwork and briefing information. Depending on clinic capacity, briefing can be completed individually or on a group basis, and can consist of written materials, briefing by staff or pre-recorded presentations on video if facilities are available. This may require translators and translated materials to reflect the local population. Issues to be addressed include:
• information about the prophylactic medication risks and benefits
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• contraindications • what to expect during the administration/dispensing process including, if necessary, refill information
• signs of complications and immediate reporting instructions
• any other important details • information on completing the registration material and consent forms.
In situations where alternate treatment or assessment sites are part of the response, these sites may also serve as destinations. Step 2: Oral Medication-Based Clinic: Health Assessment
After paperwork is completed, medication recipients are routed to the medical assessment stage. At this point the staff performing this function will:
• discuss possible contraindications and whether alternate dosage/medication is indicated
A number can be assigned to recipients for traffic control.
• review common reactions to the
Following the briefing, time is allowed for recipients to complete the required paperwork (including consent forms) and ask questions. Separate areas may be set aside for orientation, or orientation locations can also serve as holding locations.
• confirm that no current illness
Step 1.5: Oral Medication-Based Clinic: InDepth Health Evaluation
If flagged during the orientation and screening process or health assessment, recipients may be routed for more in-depth health evaluation in order to further assess eligibility, determine appropriate next steps, or to recommend an alternate medication or dosage than the standard one being dispensed. Depending on the emergency, recipients may be required to wear surgical masks in this area and, if routed back for prophylaxis, throughout the dispensing process. Following the health evaluation, patients may be routed:
• back into the dispensing process (with or without surgical masks)
• to appropriate level of medical care, e.g. acute-care facility
• home.
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medication with each recipient requiring more in-depth medical evaluation is present
• ensure consent form is signed if required. After this assessment, recipients may be routed either back for more in-depth medical evaluation (see Step 1.5), or forward to Step 3. Step 3: Oral Medication-Based Clinic: Dispensing
After assessment, prophylaxis recipients with no medical contraindications are ready to receive their medication. Those who are being given the standard dosage can be routed to an express dispensing station. Those who require alternate medication or adjusted doses can be routed to an assisted dispensing station. At the appropriate station, the necessary follow-up information will be given, including a reiteration of the information regarding obtaining refills, and the necessary documentation completed and collected. The collection of completed forms from the dispensing stations is a staff function that must be assigned.
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Ontario Health Plan for an Influenza Pandemic August 2008 Step 4: Oral Medication-Based Clinic: Exit
Once the recipients have received their medication, they will be informed that they are finished with the process and routed to the exit. 4. Clinic Staff Structure
As discussed, the functions assigned to various staff may vary with the clinic size and setting. However, it is recommended that the Incident Management System (IMS)
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(see Chapter 2) be used for the clinic command structures as well as for each jurisdiction’s coordinating committee. Job action sheets for all staff functions should be developed. More detail regarding suggested staff functions, both at the management and coordination level and for patient interaction and clinic operation, is provided in Appendix A, including sample job actions sheets.
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Appendix A: Staff Functions The following is a summary of suggested staff roles and responsibilities, aligned with an IMS structure. As previously discussed, this may vary with clinic size and setting. 1. Operations Coordinators:
• Clinical Leader: Oversees clinical aspects of clinic.
• Nurse Coordinator: Oversees nursing staff assigned to the clinic; assists site manager in making clinic assignments for nursing staff; assists on-duty nurses as needed. Direct Service Staff
• Greeter-Screeners: Greet and enquire about the presence of current symptoms; route as appropriate to registration phase or in-depth medical evaluation.
• Registration Staff: Confirm eligibility; create patients record and provide clinic documents and informational materials.
• Educators: conduct orientation; provide basic information (verbally or with a video presentation) about the vaccine and the immunization process; explain how to complete the documents and answers questions about completing documents.
• Health Screeners: Assess clients for contraindications or, with oral medications, need for adjusted dosage, alternate drug; review common reactions; answer medical questions; refer to more in-depth medical evaluation if needed. (Generally filled by a physician, nurse or paraprofessional with good
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interviewing skills and relevant knowledge.)
• Immunization Assistants: Assist the vaccine administrator with all aspects of pre- and post- immunization activities; ensure that immunization station maintains adequate supplies; instruct recipients on location of immunization; assist vaccine recipients in preparing the immunization site (roll up sleeve, remove arm from shirt/blouse, etc.); instructs clients about site care.
• Dispensing Assistants: Work in dispensing area to package and label medications in preparation for administration to clients.
• Vaccine Administrators: Oversee the immunization process; clean immunization site; administer the vaccine; sign the clinic record; observe vaccine recipients for immediate reaction or complications.
• Dispensers: dispense medication; for patients needing assistance, determine alternate/adjusted dose; explain course of medication; sign the clinic record; observe recipients for immediate reaction or complications.
• Other Clinical/Nursing staff: May include nurse team leader to ensure clinic is running smoothly and troubleshoot; nurse practitioners or physicians in medical evaluation area, for immunization campaigns nurses dedicated to vaccine reconstitution/draw-up process; nurses to monitor people in postimmunization area.
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• Clinic Flow Controllers: Direct vaccine recipients through the clinic process and monitor clinic flow; work with security staff to monitor bottlenecks, possible situations where security action needed.
• Emergency Medical Personnel: Respond to medical emergencies including reactions ranging from the minor to anaphylactic shock and serious medical emergencies that are incidental and unrelated to immunization. For large operations, local public health units may wish to have a physician, nurse practitioner or emergency paramedic on-site at all times during clinic operations. 2. Planning
• Data Analyst: reviews information gathered through screening and registration process to determine uptake, support planning regarding clinics operations, and flag emerging issues. 3. Logistics Logistics Coordinator
Works with Supply and Transportation Team to ensure that:
• all necessary clinic supplies are on site and are available in sufficient quantities during clinic operations;
• all necessary clinic staff are onsite • an inventory of supplies is maintained; and distributed to/maintained at appropriate locations in the clinic;
• sufficient drug/vaccine is available, and cold chain is maintained through proper handling and storage;
• medication is stored in a secure manner at the clinic site and that unused
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amounts are returned and accounted for. Other Logistics Personnel:
• Inventory Clerk: oversees, replenishes within the clinics, and reorders supplies.
• Runners: bring supplies for immunization reconstitution and drawup/ medication packaging area to tables;
• Supply and transportation team: keep clinics stocked from central stores during day and make sure staff have transportation to clinic site;
• Support staff: address child care, food preparation and housekeeping and custodial services.
• Security Coordinator: Oversees personnel assigned to security activities at the clinic site; assists the site manager in making duty assignments of security personnel; determines appropriate number of security staff necessary according to clinic size and location; maintains a list of authorized clinic staff and their phone numbers; assigns and coordinates use of cell phones and pagers; establishes staff check-in and check-out procedures; ensures that all staff wear ID badges; maintains communication with local law enforcement officials.
• Security Staff: Ensure an orderly flow of traffic and parking at the clinic site; assist in maintaining orderly movement of vaccine recipients through the clinic process; provide necessary control if persons become unruly; assist supply officer in maintaining security of medications and other clinic supplies.
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4. Administration and Finance
• Site Manager: Oversees administrative aspects of clinic.
• Volunteer Coordinator: Oversees volunteer activity at the clinic site. Assists the site manager in making duty assignments of volunteer staff; maintains roster of persons available for volunteer duty; and maintains a
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schedule of times that volunteers will be available to work.
• Forms Collectors/Clerks: Form collectors verify that forms are correctly completed; collect all necessary forms from immunization/dispensing stations; clerks assist with clinic administrative paperwork (e.g., requisition forms).
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Appendix B: Supply Lists for Pandemic Influenza 1. Supplies: Injection-Based Clinic Medical Supplies
Emergency supplies
Appropriate syringes with needlesgauge & syringe size TBD
Blood pressure cuffs, adult
Alcohol swabs
Blood pressure cuffs, child
Medium Cotton Balls
Stethoscopes
Band-Aids
Epinephrine 1:1000 ampules
Latex gloves (powdered/non-powdered)
Syringes and needles to administer epinephrine
Non-latex gloves (powdered/non-powdered)
MOHLTC Epinephrine Medical Directive
Alcohol hand rinse and hand soap
Anaphylactic fact sheets on dosage, etc.
Surgical Masks for Recipients
Emergency supplies bag (1 per clinic)
N95 Respirators for staff Paper Gowns
Incident reports
Paper towels
Adverse reaction reporting sheets
Sterile gauze pads (7.6cm x 7.6cm)
Pens (red &blue)
Hypoallergenic Tape (2.5cm x 9.1m)
Cell phones
Sharps containers (large) Biohazard waste boxes & yellow bags (24 per box) Paper square absorbent table cover
Paper supplies
Garbage bins (15 per site)
Consents
Garbage bags (clear)
Immunization Slips
Promotion material for waiting & recovery areas
Sore arm slips
Tables
Pens
Chairs
Staplers
Vaccine supplies (based on 10 dose vials [actual 9 dose/vial])
English fact sheets
Vials of vaccine
Translated fact sheets (languages TBD)
Cooler Bags
Translated contra-indication cards
Ice Packs
Date stamp & stamp pads
Thermometers
Flip Chart and/or White Board
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2. Supplies: Oral-Medication-Based Clinic Medication distribution supplies
Emergency supplies
Antiviral medication doses
Blood pressure cuffs, adult
Envelopes/ containers for medication storage
Blood pressure cuffs, child
Medication labels
Stethoscopes
Paper supplies (based on 1 Vaccination centre)
Anaphylactic fact sheets on dosage, etc.
Consents
Emergency supplies bag (1 per clinic)
Pens
Incident reports
Staplers
Pens (red & blue)
English fact sheets
Cell phones
Translated fact sheets (languages TBD) Translated contra-indication cards Date stamp & stamp pads Flip Chart and/or White Board or poster
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Appendix C: Local Public Health Units Algoma Health Unit
705-759-5287
Brant County Health Unit
519-753-4937
Chatham-Kent Public Health Services
519-352-7270
Durham Regional Health Unit
905-668-7711
Eastern Ontario Health Unit
613-933-1375
Elgin-St. Thomas Public Health
519-631-9900
Grey Bruce Health Unit
519-376-9420
Haldimand-Norfolk Health Unit
519-426-6170
Haliburton, Kawartha, Pine Ridge District Health Unit
905-885-9100
Halton Region Health Department
905-825-6000
City of Hamilton - Public Health & Social Services
905-546-2424
Hastings & Prince Edward Counties Health Unit
613-966-5500
Huron County Health Unit
519-482-3416
KFL&A Public Health
613-549-1232
County of Lambton Community Health Services Department
519-383-8331
Leeds, Grenville and Lanark District Health Unit
613-345-5685
Middlesex-London Health Unit
519-663-5317
Niagara Region Public Health Department
905-688-3762
North Bay Parry Sound District Health Unit
705-474-1400
Northwestern Health Unit
807-468-3147
Ottawa Public Health
613-580-6744
Oxford County – Public Health & Emergency Services
519-539-9800
Peel Public Health
905-799-7700
Perth District Health Unit
519-271-7600
Peterborough County-City Health Unit
705-743-1000
Porcupine Health Unit
705-267-1181
Renfrew County & District Health Unit
613-732-3629
Simcoe Muskoka District Health Unit
705-721-7520
Sudbury & District Health Unit
705-522-9200
Thunder Bay District Health Unit
807-625-5900
Timiskaming Health Unit
705-647-4305
Toronto Public Health Unit
416-392-7401
Region of Waterloo, Public Health
519-883-2000
Wellington-Dufferin-Guelph Public Health
519-846-2715
Windsor-Essex County Health Unit
519-258-2146
York Region Public Health Services
905-895-4511
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Appendix D: Clinic Process Flow Chart – Injection-Based Clinic
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Appendix D: Clinic Process Flow Chart – Oral Medication-Based
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Ontario Health Plan for an Influenza Pandemic August 2008
References ANNEX D: Planning for Mass Immunization. British Columbia Centre for Disease Control. Beynon R, Oberle M, Wicklund J, Stevermer A, Boase J, Owens D. Evaluation of the Washington State National Pharmaceutical Stockpile* Dispensing Exercise: Part I – Patient Volunteer Findings. J Public Health Manag Pract. 2003 Sep; 9(5): 368-376. Guide to Planning a Mass Immunization Campaign: Lessons learned from the Waterloo Region Meningococcal Outbreak; December 1997. Waterloo Ontario: Waterloo Region Health Department ON; January 2001. Hupert N, Cuomo J, Callahan MA, Mushlin AI, Morse SS. Community-Based Mass Prophylaxis: A Planning Guide for Public Health Preparedness. AHRQ 2004; Aug: 04-0044. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/research/cbmprophyl/ Immunization Operation Program Policy and Procedure Manual; May 2005. Region of Peel, ON. Anderson, J. ANNEX Pandemic Influenza A Mass Immunization and Anti-Viral Plan. December 2004. York Region Health
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Services Infectious Disease Control Division, Ontario. Mass Meningococcal Immunization Campaign in Middlesex – London, 2001: Critical Elements for Success. MiddlesexLondon Health Unit, Ontario. September 2002. Nolan P. The Rhode Island Meningitis Vaccine Experience – Mass Vaccination Campaigns, Politics and Health Policy. Rhode Island. Med Health. 2004 Mar; 97: 3. Safety of Mass Immunization Campaigns. Department of Vaccines and Biologicals, World Health Organization. Available at: http://www.who.int/vaccines Stein B, Tanielian T, Eisenman D, Donna K, Burnam A, Pincus H. Emotional and Behavioral Consequences of Bioterrorism: Planning a Public Health Response. Milbank Q. 2004; 82( 3):413-455. Ontario Smallpox Response Plan (in progress), Ontario Ministry of Health and Long-Term Care U.S. Centre for Disease Control and Prevention, CDC Interim Smallpox Response Plan and Guidelines Available at: http://www.cdc.gov/iceid/webcast/ smallpox_response.htm
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Immunization Training Manual I. Introduction This document is a resource to help local public health units in Ontario train people to administer vaccines in the event of an influenza pandemic or other health emergency requiring the activation of the Ontario Mass Emergency Immunization/Prophylaxis Plan. It is not meant to apply to seasonal influenza immunization campaigns. During an influenza pandemic, Ontario’s goal is to obtain enough vaccine for the entire population but vaccine will be in short supply during the early stages of a pandemic. Once sufficient doses of pandemic influenza vaccine are available, Ontario will use primarily a “pull” strategy to ensure best use of available resources: influenza vaccine will be sent only to public health units, which will organize mass immunization clinics, and people will attend the clinics to be immunized. Objectives of the Pandemic Vaccine Program
1.
To provide a secure supply of safe, effective vaccine for all Ontarians as quickly as possible.
2.
To store, distribute, allocate and administer vaccine supplies efficiently and appropriately.
3.
To monitor the safety and effectiveness of vaccine programs.
Influenza
Influenza, commonly known as “the flu,” is a serious contagious illness caused by a virus, which infects the respiratory system (nose, throat, lungs). People of any age can get influenza.
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Symptoms usually start with a headache, chills and cough which are followed rapidly by high fever, extreme tiredness, sore throat, runny or stuffy nose, and muscle aches. Children can also get earaches, nausea, vomiting, and diarrhea. Uncomplicated illness due to influenza typically lasts from three to seven days, but it can last longer. The cough and fatigue can persist for several weeks, making the return to full personal and work activities difficult. While most healthy people recover from influenza without complications, some people – such as people 65 years of age and older, very young children, and people with chronic medical conditions – are at high risk for serious complications from influenza. How Influenza Spreads
The highly contagious influenza virus is directly transmitted from person to person when people infected with the virus cough or sneeze, and droplets of their respiratory secretions come into contact with the mucous membranes of the mouth, nose and possibly eyes of another person. Influenza can also be transmitted indirectly when people shake hands with infected persons or touch contaminated surfaces and objects, and then transfer the virus to themselves by touching their eyes, nose or mouth. During certain medical procedures, droplets containing influenza virus may become aerosolized and spread through the air. Current scientific evidence has not confirmed or ruled out the spread of influenza through the air in other circumstances (i.e., other than procedures that create aerosols).
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The incubation period for influenza is from one to three days. People with influenza are infectious and may be able to transmit the virus for up to 24 hours before the onset of symptoms, and for up to five days after, longer for children.
Immunizations, hand hygiene, respiratory etiquette (covering one’s mouth when coughing or sneezing, proper tissue disposal) and prophylaxis with antivirals (if available) are the best ways to reduce the risk of getting and spreading influenza.
People with influenza tend to shed more virus in their respiratory secretions in the early stages of the illness. Viral shedding tends to last longer in infants, young children and people with weak or compromised immune systems.
Pandemic Vaccine Product
Pandemic Influenza
Pandemic influenza is a type of influenza that occurs every few decades and spreads rapidly around the world affecting many millions of people. Pandemics happen when a new influenza virus develops that few people have immunity against. Unlike seasonal influenza that occurs every winter, pandemic influenza can occur at any time of the year. Pandemic influenza is likely to cause the same symptoms as seasonal influenza but the symptoms may be more severe and varied (e.g. neurological symptoms), causing more serious illness and more deaths. More than a quarter of the population could be affected. A pandemic is likely to cause many deaths, disrupt the daily life of people, and cause intense pressure on the healthcare system and all other essential services. II. Influenza Vaccine Vaccines are the primary means to prevent disease and death from influenza during an epidemic or pandemic. One of the assumptions guiding planning for an influenza pandemic is that a pandemic influenza vaccine will not be available for at least four to five months after the pandemic virus strain is identified and will likely not be available during the first pandemic wave.
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A pandemic influenza vaccine can only be developed once the strain of the circulating pandemic virus has been identified. The vaccine manufacturer will begin production once the seed strain has been provided. The federal government is responsible for vaccine supply, including developing the domestic infrastructure, maintaining a standby supply of fertilized hens’ eggs ready to convert into vaccines, phasing in new technologies, and ensuring security of supply (i.e., via a pandemic contract). Once a vaccine has been developed (i.e., four to six months after the pandemic strain is identified) a domestic supplier guarantees to manufacture vaccine, and the goal is to provide enough vaccine for everyone to receive one dose within a month. When the vaccine has been developed, a product monograph will be available, which will provide additional information. III. Vaccine Storage and Handling Guidelines The MOHLTC’s Vaccine Storage and Handling Guidelines can be accessed at https://www.publichealthontario.ca The Importance of Cold Chain
Vaccines are sensitive biological substances that can lose their potency and effectiveness if they are exposed to heat and/or direct sunlight or fluorescent light. Certain vaccines lose potency when exposed to room temperature for as little as 30 minutes. Freezing damages most vaccines. The loss of vaccine potency cannot be reversed.
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Vaccines may be wasted if they have been exposed to temperatures below +2oC or above +8oC, and are spoiled, or if they have expired before they can be used. Storage Guidelines for Immunization Clinics (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module. October 2007)
The clinic coordinator will be responsible for transporting vaccine to and from the clinics, along with the required number of ice packs.
• Use insulated containers and ice packs when transporting vaccines.
• Store all vaccines between +20C and + 0
8 C.
• To avoid freezing, do not place vaccine directly on an ice pack (tuck into pocket of towel wrapped around the ice pack).
• Remove vaccines from insulated bag only for withdrawal of the required dose(s).
• Check expiry dates on the vaccine vial Vaccines expire at the end of the month listed (i.e. expiry Oct/2006 means October 31, 2006). IV. Health Care Consent Act (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
The Health Care Consent Act (HCCA), 1996 sets out certain requirements for consent for treatment and how consent must be obtained. Immunization is considered a treatment and therefore requires consent. The consent must:
• relate to the treatment being proposed • be informed • be voluntary, and not have been obtained through misrepresentation or fraud.
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Giving Consent
A person is capable of giving consent to immunization, if he or she:
• understands the information that is important to making a decision concerning immunization and
• appreciates the consequences of a decision or lack of a decision. There is no minimum age for giving consent. This means a grade 7 student can give consent regardless of a parent’s wishes. Practitioners giving immunizations must use professional judgment to decide whether the student understands and appreciates the information needed to give informed consent. Documentation should describe the decision-making process used to assess capacity (see College of Physicians and Surgeons consent policy and College of Nurses Consent Standard). Informed Consent
Consent is informed, if before giving it:
• the person received information about the issue/treatment requiring consent (i.e., the same information that any person in the same circumstances would require in order to make a decision) and
• the person received answers to his or her requests for additional information about the issue/treatment (e.g., nature of the treatment, expected benefits, materials risks and side effects, alternative courses of action, likely consequences of not having the treatment). Practitioners giving immunizations must use professional judgment to decide whether the person understands and appreciates the information needed to make the decision. A signed consent form is not
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required. The Role of the Parent/Guardian
Parents or legal guardians of children who are too young to understand the risks and benefits of immunization may consent on behalf of their child. Foster parents are able to consent on the behalf of foster children in their care. Grandparents, aunts, uncles, older siblings, child care providers, nannies or baby sitters who are not the legal guardian of a child cannot consent on behalf of the parent. They may present a consent form that a parent has signed if the parent is unable to attend a clinic with their child. The nurse must consider whether the client/guardian is capable of giving consent. If the person is not felt to be capable, the nurse will defer the immunization until a substitute decision maker is available. A substitute decision maker is someone authorized by the Ontario Health Care Consent Act to make decisions related to health care on behalf of an individual who has been deemed incapable of making his/her own decisions. In the case of children, parental consent can be obtained through a letter from the parent or verbal consent given to the immunizing nurse. Revoking Consent
A person/guardian/substitute decisionmaker can revoke consent any time prior to the vaccine being administered. If a person revokes consent, the nurse will defer the immunization, explore the person’s rationale for not consenting and review the importance of the influenza immunization as well as its risks and benefits. If consent is still not obtained, the person can be referred to another influenza clinic or to their primary care provider.
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V. Administration of Pandemic Influenza Vaccine Physician's policy and medical directives: Reference: College of Physicians and Surgeons http://www.cpso.on.ca/Policies/delegation.htm
Medical directives are blanket instructions by physicians (often more than one) to other health care providers. They pertain to any patient who meets the criteria set out in the medical directive. The medical directive contains the delegation and provides the authority to carry out the treatments, interventions or procedures that are specified in the directive, providing that certain conditions and circumstances exist. In most cases, medical directives are used to ensure that health care can be delivered without a physician’s direct assessment of the patient or direct supervision. Their use is especially frequent in institutional settings. A medical directive must always be written and must comply with the principles set out in this policy. Guidelines about the use and development of medical directives, as well as a prototype of a medical directive can be found in the CPSO policy. A more comprehensive guide and toolkit is posted on the Federation of Health Regulatory College of Ontario’s (FHRCO) website at http://mdguide.regulatedhealthprofessions .on.ca/why/default.asp This guide was developed by a working group of FHRCO in 2006. The toolkit provides templates for construction of Medical Directives, as well as explanations of how to establish the prerequisites. The templates will have the most direct application for large institutional settings, but anyone who wishes to establish a Directive (or to learn more about delegation) will find them helpful. Their use is not mandatory, but any
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physician who delegates a controlled act pursuant to a Medical Directive developed using these templates will be in compliance with the legislation and College policy and will be providing the very best quality of care to patients.
intramuscular route. Certain common body sites are used for intramuscular injections. The site selected will depend on the person’s age, skin and muscle condition, the volume of vaccine being administered and any manufacturer’s specification.
Medical Directives Adapted from the College of Nurses of Ontario Practice Guideline: Medical Directives, Rev. 2000.
Medical directives are required for nurses to administer vaccines. Medical directives are always written and, for the purposes of mass immunization during an influenza pandemic, will be signed by a physician (the local medical officer of health). Information in a Medical Directive
Medical directives need to include the following information:
• the name and description of the procedure(s)/ treatment(s)/intervention(s) being ordered;
• specific client clinical conditions and
Table 1: Vaccine Injection Sites Age Group
Preferred Site
infants (<1 year of age)
vastus lateralis muscle in the anterolateral area of the middle to upper thigh
children and adults
deltoid muscle
Particular landmarks will identify the exact point of needle insertion for an IM injection. Theses landmarks are illustrated below. (Source of illustrations is Kozier & Erb.) Note: The buttock should not be used for active immunization for either children or adults (Canadian Immunization Guide 20006 p. 40)
situational circumstances that must be met before the procedure(s) can be implemented;
• clear identification of the contraindications for implementing the directive;
• the name and signature of the physician approving, and taking responsibility for, the medical directive; and
• the date and signature of the administrative authority approving the medical directive. Guidelines for Administering Vaccines by Intramuscular Route (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
Influenza vaccines should be given by
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Vastus lateralis site
Locate the middle third of the vastus lateralis (thigh) as shown:
• IM site for infants and toddlers (under 1 year of age) • Insert needle at 80º - 90º angle into vasus lateralis muscle in anterolateral aspect of middle or upper thigh.
• Do NOT administer any injections in the gluteus maximus area in infants, children or adults.
Deltoid
Locate the triangle that lies between the lower edge of the acromion process and the midpoint on the lateral aspect of the arm that is in line with the axilla as shown below:
• IM site for older toddlers, children, and adults • Insert needle at 90º angle into densest portion of deltoid muscle - above armpit and below acromion.
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Procedure for Preparing Vaccines
Materials and Supplies Needed:
(Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
vaccine in cooler bags
This is the standard procedure to be used in community clinic settings where the dosage may vary depending on the age of the client but only one vaccine is being administered.
1” needles
1.
loader needles (18 or 20 gauge) alcohol swabs biohazard containers ice packs towelling for inside cooler bags or to wrap ice packs
Nursing staff may administer vaccine that has been prepared by another nursing staff member at a central loading table. Only RN or RPN staff members can prepare and withdraw the vaccine into syringes at the loading table.
2.
pens alcohol-based hand sanitizer.
syringe from the loader needle by grasping the plastic hub of the loader needle and gently unscrewing the syringe (leaving the loader needle in the vial).
All syringes prepared at the vaccine loading table will have a 0.5 ml dose loaded (for persons age 3 or older).
3.
Vaccine vials will be kept in the vaccine cooler bag until needed.
4.
Staff should perform hand hygiene, upcap vial and cleanse stopper with isopropyl and allow to dry prior to filling the syringes. Use an alcoholbased hand sanitizer, or if hands are visibly dirty, wash hands for at least 15 seconds using soap and running water.
5.
3 cc syringes
To load from a multiple dose vial: • Attach an 18 or 20 gauge needle to the first syringe (do not tighten too securely). •
•
Check the vial to see if any particles present (faulty stoppers will sometimes “core” as the loader needle is passed through them). Withdraw one 0.5 ml dose into the syringe, remove any air bubbles by tapping and then detach the
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6.
•
Attach a 1” 25 gauge needle to the syringe and immediately place the loaded syringe into the pocket of the cloth-covered ice pack.
•
Attach a new syringe to the loader needle and again withdraw the next dose. You do not need to inject more air as the pressure in the vial will equalize each time the syringe is detached from the loader needle.
•
If the full number of doses is not withdrawn, attach a syringe to the loader needle and leave it in place (to prevent any contamination from entering) or remove the loader needle from the vial and discard the needle. When a vial has been emptied, remove the loader needle from the vial and discard it in the biohazard container. Place the empty vaccine vials into the appropriate disposal unit (e.g., an orange garbage bag).
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Vials that are broken/shattered should be disposed of in the biohazard container. 7.
For children under the age of 36 months requiring a dose of 0.25 ml, a vial of vaccine will be kept at each immunization station for loading by the immunizing nurse immediately prior to immunizing the child.
cover and use the non-dominant hand to spread the skin at the injection site. 7.
Holding the syringe between thumb and forefinger, pierce the skin at a 900 angle to the skin surface. The needle should be inserted quickly and in one motion.
8.
Pull back on the plunger to determine whether the needle is in a blood vessel. If blood appears in the syringe, discard the syringe and prepare a new injection.
9.
If no blood appears on aspiration, slowly and steadily inject the medication.
10.
Withdraw the needle.
11.
Without recapping the needle, dispose of the syringe and needle in the biohazard (sharps) container.
12.
If the injection site is bleeding, place a bandage on the site.
13.
Document all pertinent information (lot #, date, time, site, comments and signature) on the individual's
Procedure for Injecting Vaccines by the Intramuscular Route (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
1.
2.
3.
4.
5.
6.
Complete the verification and screening of the consent with the individual or parent. Select the proper needle size to reach the muscle (syringes will be fitted with a 1” 25 gauge needle at the loading station). The recommended needle length of infants, toddlers, and older children is 7/8” to 1” and for adolescents and adults is 1” to 1 ½” (Public Health Agency of Canada, 2006). For individuals requiring a 0.5 ml dose, check that the loaded syringe contains the proper dose and make any adjustment of needle size. For children requiring a 0.25mL dose, draw up the appropriate dose into the syringe from the vaccine vial located at the immunization station (refer to step 5 in Preparing Vaccines). Cleanse the injection site with an alcohol swab, beginning at the centre and moving outward in a circular motion, and allow to dry. Gently agitate the syringe to mix any settled vaccine, remove the needle
Chapter #9A: Antivirals and Vaccine Tools
Materials and Supplies Needed at Immunization Tables table and chairs garbage container biohazard container alcohol swabs date stamp and pad pen immunization record bandages cotton balls if necessary wrapped ice pack for vaccine syringes extra vial of vaccine in ice pack empty 3 cc syringes (kept separate from loaded syringes) additional 1” or 5/8” needles alcohol-based hand sanitizer.
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Ontario Health Plan for an Influenza Pandemic August 2008
consent (which constitutes the record). Record any reactions following the injections on the back of the consent form for that individual. 14.
Perform hand hygiene between vaccine recipients.
• Perform hand hygiene before and after glove use.
• Dispose of gloves in garbage container – not the biohazard container. Sharps
• Never recap needles after Infection Prevention and Control Practices for Immunization Clinics (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
Hand Hygiene
• “Hand hygiene should be performed before vaccine preparation, between vaccine recipients, and whenever hands are soiled.” (Public Health Agency of Canada, 2006, p. 43)
• Use an alcohol-based hand sanitizer to decontaminate your hands when your hands are not visibly soiled
• Clean visibly soiled hands with plain
immunizing
• Immediately and carefully discard dirty needles directly into the biohazard sharps container (for immediate disposal i.e.: don’t put it down onto the table first)
• Keep biohazard containers on the table – never on the floor
• Securely cover all biohazard containers with lids supplied prior to moving them
• Watch young children around the immunization table to ensure they don’t reach for the biohazard container.
liquid soap and running water
• Wash with soap and water whenever hands have contact with secretions, excretions, blood and body fluids. Gloves
• “Glove use during immunization is not routinely recommended, unless the skin on the vaccine provider’s hands is not intact” (Public Health Agency of Canada, 2006, p. 43). Gloving is not required for immunization staff with intact skin.
• Glove if providing first aid to someone who has suffered a cut due to a fall or faint.
• Gloves must be changed regularly and when contaminated with blood or other body fluids
Chapter #9A: Antivirals and Vaccine Tools
Procedure to Follow in the Event of a Needle-Stick Injury (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
Any needle-stick injury from a needle that has been used in providing an immunization to a known client or a used needle from an unknown source should be reported to and followed up by the employer of the staff member involved. An injury due to contact with a loader needle does not constitute a risk for bloodborne pathogens, but should be reported. If you receive a needle-stick injury after completing an immunization for a client or have an injury due to an exposure to a needle from an unknown source (biohazard container spills or a sharp has
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Ontario Health Plan for an Influenza Pandemic August 2008
frequency of some side effects in adults.
punctured the container), follow these immediate steps: Step 1: Administer first aid:
2.
Direct the vaccine recipient(s) to the waiting area and ask them to remain for 15 minutes prior to departing from the clinic site. Advise them to report any immediate reactions or concerns to staff.
3.
Advise clients that the Immunization Record (yellow) is the certificate of Immunization that may be required by places of employment, schools or sites where they provide volunteer services.
• allow puncture site to bleed freely • wash area well (two to four minutes) with soap and water
• cleanse area with alcohol wipe • apply dressing (if necessary) to puncture site. Step 2: Report the injury to the clinic coordinator and to your manager and complete an incident form. Step 3: Advise the clinic coordinator if you know the source and they will do a quick screening to determine if the client has any risk factors for blood-borne diseases. Step 4: Seek medical attention. Immunization “After Care” Guidelines (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
Give the vaccine recipient or parent/guardian the appropriate “Immunization Record” slip and advise them that common post-immunization symptoms include: • A slightly sore arm for up to two days (reported by 1/3 of vaccines) and •
•
Less frequently – a systemic response of fever, malaise and aching muscles starting 6 to 12 hours after immunization and persisting up to 2 days (especially in those persons receiving influenza vaccine for the very first time) Acetaminophen in doses outlined by the manufacturer for over the counter use may decrease the
Chapter #9A: Antivirals and Vaccine Tools
Guidelines for Documentation Related to Vaccine Administration (Adapted, with permission, from the Region of Waterloo Public Health Influenza Immunization Program Training Module, October 2007)
The client record: For the purposes of vaccine administration, the client's consent form constitutes the client record. Additional documentation of reactions or incidents can be completed on the back of the consent form. If additional pages are necessary, identify theses with the client’s personal information as indicated below. Attach all extra pages by stapling. Client information: The following personal client information is collected in accordance with legal privacy and information requirements:
• name, first name and surname and date of birth
• address and telephone number. Nursing documentation guidelines:
• Record any relevant information that was obtained during the screening process
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Ontario Health Plan for an Influenza Pandemic August 2008
• Immediately following the administration of vaccine, document the following information on the client record: • date vaccine was given •
name of vaccine
•
dosage
•
route of administration
•
site of injection
•
vaccine lot number
•
signature and status of nurse who administered the vaccine.
• Document any significant client response to the vaccine (i.e. adverse events, feeling faint, immediate skin reactions on the back of the consent form along with actions taken or persons notified)
• If the vaccine is withheld or a second injection is required due to aspiration of blood in the syringe or client moved before injection was complete, document the reason
• Sign the documentation, indicating professional status, i.e., R.N. or R.P.N
• In the event of a medication incident, follow the procedure and staple the report to the client’s record. 6. Adverse Events Following Immunization The MOHLTC collects information on some Adverse Events Following Immunization (AEFI) through the Integrated Public Health Information System (iPHIS). These case reports are then reported to the Public Health Agency of Canada (PHAC) and stored in the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS). Through this database, the safety of vaccines in Canada can be
Chapter #9A: Antivirals and Vaccine Tools
monitored. Under section 38 of the Health Protection and Promotion Act, a physician, a member of the College of Nurses of Ontario or a member of the Ontario College of Pharmacists who, while providing professional services to a person, recognizes the existence of a reportable event and forms the opinion that it may be related to the administration of an immunizing agent must report the “reportable event” to the local medical officer of health, within seven (7) days after the reportable event is recognized. A “reportable event” includes the following:
(a) persistent crying or screaming, anaphylaxis or anaphylactic shock occurring within 48 hours after the administration of an immunizing agent
(b) shock-like collapse, high fever or convulsions occurring within three (3) days after the administration of an immunizing agent
(c) arthritis occurring within 42 hours after the administration of an immunizing agent
(d) generalized urticaria, residual seizure disorder, encephalopathy, encephalitis or any other significant occurrence [significant occurrences that are unexpected or unusually severe such as Oculo-Respiratory Syndrome (ORS), Guillain-Barré Syndrome (GBS)] occurring within 15 days after the administration of an immunizing agent
(e) death occurring at any time and following upon a symptom described in clause (a), (b), (c), or (d).
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Ontario Health Plan for an Influenza Pandemic August 2008
Common Adverse Reactions
to onset of a reaction foretell more severe reactions. Vaccine recipients should be kept under supervision for at least 15 minutes after immunization. In low risk situations, supervision can include having immunized people remain within a short distance of the vaccinator (e.g., within a school being used for immunization) and return immediately for assessment if they feel unwell.
• fainting – occurs when an individual temporarily loses consciousness which is caused by diminished blood supply to the brain due to an emotional reaction or a painful stimulus.
• anxiety attack - People experiencing anxiety may appear fearful, pale and sweaty and complain of lightheadedness, dizziness and numbness, as well as tingling of the face and extremities. Breathing too quickly (hyperventilation) is usually evident. Treatment consists of reassurance and breathing into a paper bag until symptoms subside.
• breath-holding spell - Breathholding spells occur in some young children when they are upset and crying hard. The child is suddenly silent but obviously agitated. Facial flushing and blueness around the mouth deepens as breath-holding continues. Some spells end with resumption of crying, but others end with a brief period of unconsciousness during which breathing resumes. No treatment is required beyond reassurance of the child and parents.
• severe allergic reactions (anaphylaxis) - Anaphylaxis is a potentially life-threatening allergic reaction. Pre-immunization screening should include questions about a possible allergy to any component of the product(s) being administered. Anaphylaxis is a rare complication of immunization but should be monitored for after every immunization. Most instances of anaphylaxis begin within 30 minutes after an injection of vaccine. Shorter intervals
Chapter #9A: Antivirals and Vaccine Tools
Management of Anaphylaxis (Adapted, with permission, from Immunization Manual Procedure, Management of Anaphylaxis, Perth District Health Unit. The Perth District Health Unit provided the following guide for the purpose of developing policy and procedures for immunization clinics, and the Ministry of Health and Long-Term Care is providing it here for information purposes only.)
“Anaphylaxis is a potentially lifethreatening allergic reaction to foreign protein antigens such as food and bee stings. It is a rare complication of immunization but, even so, it should be anticipated in every vaccine”. Anaphylaxis is rare and based on national reports, the annual rate ranges from 0.4 to 1.8 reports per 1,000,000 doses of vaccine distributed in Canada (Canadian Immunization Guide. Public Health Agency of Canada; 2006. p. 80) o
If the patient is experiencing symptoms of anaphylaxis (facial, respiratory or cardiovascular involvement - shortness of breath, wheezing, hypotension, and any swelling of face or mouth/tongue) promptly administer epinephrine 0.01 ml/kg (maximum of 0.5 ml) of aqueous epinephrine (adrenalin) 1:1,000 by subcutaneous or intramuscular injection in the opposite limb to that in which the
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Ontario Health Plan for an Influenza Pandemic August 2008
immunization was given. Speedy intervention is of paramount importance: failure to use epinephrine promptly is more dangerous than using it improperly. o
Call for assistance, including an ambulance.
o
Place the patient in a recumbent position (elevating the feet if possible). Remember that patients experiencing shortness of breath may be unwilling or unable to lie down.
4.
5.
6.
Assess airway, breathing and circulation. Establish an oral airway if necessary. Begin CPR if patient is Vital Signs Absent (VSA). If the patient is experiencing only urticaria, rash and/or itching (no respiratory or oral symptoms) give Diphenhydramine (Benadryl). Oral treatment is preferred for conscious patients who are not seriously ill because Diphenhydramine is painful when given intramuscularly. This drug has a high safety margin, making precise dosing less important. The approximate doses of Diphenhydramine (Benadryl) are shown in Table 3. [Onset of action is 20 minutes both PO and IM administration] Repeat the epinephrine dose once in 5-10 minutes if necessary, again avoiding the limb in which the immunization was given. A different limb is preferred for each dose to maximize drug absorption. For severe cardiovascular collapse or
Chapter #9A: Antivirals and Vaccine Tools
VSA a second dose can be repeated anytime. 7.
If patient has asthma, he or she should be allowed to self administer bronchodilator as necessary.
8.
Give a dose of diphenhydramine hydrocholoride (Benadryl) as an adjunct to epinephrine to maintain symptom control in those who have responded (epinephrine being a short-acting agent).
9.
Keep patient lying down if possible. Reassure. Epinephrine causes jitters and racing hearts.
10.
Monitor pulse, blood pressure and respirations every 5-10 minutes.
11.
Arrange for rapid transport to an emergency department. Provide record of vaccine, lot number, time and dosage of adrenalin and Benadryl.
12.
Report the adverse event following immunization to the immunization clinic Manager. The Manager should inform the appropriate individuals at the health unit (i.e. Medical Officer of Health) as soon as possible.
13.
Complete a Patient Incident Employee Report form and submit to the clinic Manager.
14.
Complete an Adverse Event Following Immunization report and submit to the Medical Officer of Health. Report the adverse event following immunization in iPHIS as appropriate.
.
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Ontario Health Plan for an Influenza Pandemic August 2008
Table 2: Symptoms of Anaphylaxis and Shock Symptoms of Anaphylaxis
Symptoms of Shock
Itchy, hive-like rash in over 90% of cases.
Low blood pressure (hypotension).
Progressive, painless swelling about the face and mouth which may be preceded by itchiness, tearing, nasal congestion or facial flushing.
Rapid breathing (hyperventilation).
Respiratory symptoms including sneezing, coughing, wheezing, laboured breathing and upper airway swelling (indicated by hoarseness and/or difficulty swallowing) possibly causing obstruction.
Weak rapid pulse.
Low blood pressure which generally develops later in the illness and can progress to cause shock and collapse.
Cold clammy grayish-bluish skin.
In anaphylaxis, changes develop over several minutes and usually involve at lease two body systems affecting the skin, respiration, circulation. Unconsciousness is rarely the sole manifestation of anaphylaxis. It occurs only as a late event in severe cases.
Mental changes (a sense of great anxiety and foreboding, confusion and, sometimes, combativeness).
Table 3: Appropriate Dose of Epinephrine According to Age (Aqueous Epinephrine 1:1000) 2 to 6 months*
0.07 ml
12 months
0.10 ml
18 months to 4 years*
0.15 ml
5 years
0.20 ml
6-9 years
0.30 ml
10-13 years
0.40 ml †
≥14 years
0.50 ml †
* Dose for children between the ages shown should be approximated, the volume being intermediate between the values shown or increased to the next larger dose, depending on practicability. † For a mild reaction a dose of 0.3 ml can be considered.
Table 4: Appropriate Dose of Diphenhydramine Hydrochloride (Benadryl®) Age
Dose* Oral Children’s Liquid (6.25 mg/5ml)
Injected Adult’s Liquid (12.5 mg/5ml)
Capsules (25 mgs/1capsule)
(50 mg/ml)
< 2 years
10 ml
5 ml
N/A
0.25 ml
2-4 years
20 ml
10 ml
N/A
0.5 ml
5-11 years
20-40 ml
10-20 ml
1 capsule
0.5-1.0 ml
≥ 12 years
40 ml
20 ml
2 capsules
1.0 ml IM
*When time permits and weight is known, precise dosing can be used: - Oral dosing: 1-2 mgs/kg to a max 50 mg single dose - Injectable: 1.25 mg/kg per dose IM (or 0.025 ml/kg) to a max 1 ml single dose
Chapter #9A: Antivirals and Vaccine Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Roles and Responsibilities in Management of Anaphylaxis
In the event of a reaction to a vaccine, treatment will be administered by a public health nurse. The immunization clinic will always have two public health nurses available on site to respond immediately. Responsibilities of First Immunization Nurse (Giver):
• stay with patient - determine if there is a need to call an ambulance
• direct second immunization nurse to call ambulance with exact location of patient and reason for call
• follow the protocol for fainting and anaphylaxis as appropriate. Responsibilities of Second Immunization Nurse (Loader):
• call ambulance • assist with anaphylaxis procedure as directed by first immunization nurse, i.e. get adrenalin, 1 ml syringe and needle from anaphylaxis kit
• in the event of cardio-respiratory collapse, get a mask
• complete appropriate documentation (i.e., on Adverse Vaccine Reaction Form). Record all emergency interventions and the times that they were completed by the first immunization nurse (e.g., dose, route, site, time of adrenalin administration)
• enlist help of another team member, or volunteer to reassure other clinic attendees and for crowd control
• ensure record of vaccine, lot number, time and dosage of adrenalin and Benadryl are given to ambulance attendants.
Chapter #9A: Antivirals and Vaccine Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 1: Anaphylaxis Treatment Algorithm – In a Clinic Setting – Adult
Swelling and urticarial rash at injection site
Symptoms of anaphylaxis
Observe for 30 mins Apply ice/cold pack to injection site for comfort
Progression of symptoms
Yes
Sneezing, coughing, wheezing, hoarseness, stridor Respiratory distress Clinical symptoms of shock Any oropharyngeal swelling Itchy, urticarial rash Nausea, vomiting and diarrhea (may or may not occur)
No No further care needed Administer Epinephrine 1:1000 0.30 ml – 0.50 ml IM (opposite limb from injection site) Call for assistance, ambulance Steps to be done rapidly or simultaneously
Place patient lying down, elevate feet Take vital signs and establish oral airway if necessary. Begin CPR if VSA.
Repeat epinephrine in 5 mins if no clinical improvement (This can be repeated again 5 mins later for a total of 3 doses)
Administer Benadryl® (Diphenhydramine) 50 mg po preferred – IM if unconscious
rd
NB: Patients with known asthma who develop wheezing should be allowed to administer Salbutamol or other ß-agonist
Chapter #9A: Antivirals and Vaccine Tools
Administer 3 dose of epinephrine if no clinical improvement
Transfer care to paramedics when appropriate: Verbal/written report, type of vaccine, description of reaction, treatment administered
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 2: Anaphylaxis Treatment Algorithm – In a Clinic Setting - Paediatric
Swelling and urticarial rash at injection site
Symptoms of anaphylaxis
Observe for 30 mins Apply ice/cold pack to injection site for comfort
Progression of symptoms
Yes
Sneezing, coughing, wheezing, hoarseness, stridor Respiratory distress Clinical symptoms of shock Any oropharyngeal swelling Itchy, urticarial rash Nausea, vomiting and diarrhea (may or may not occur)
No No further care needed
Administer Epinephrine 1:1000 0.07 ml – 0.50 ml IM (opposite limb from injection site) (Dosage by age) Call for assistance, ambulance
Steps to be done rapidly or simultaneously
Place patient lying down, elevate feet Take vital signs and establish oral airway if necessary. Begin CPR if VSA.
Repeat epinephrine in 5 mins if no clinical improvement (This can be repeated again 5 mins later for a total of 3 doses)
NB: Patients with known asthma who develop wheezing should be allowed to administer Salbutamol or other ß-agonist
Administer Benadryl® (Diphenhydramine) (Dosage by age) Paediatric Formula po preferred – IM if unconscious
rd
Administer 3 dose of epinephrine if no clinical improvement
Transfer care to paramedics when appropriate: Verbal/written report, type of vaccine, description of reaction, treatment administered Chapter #9A: Antivirals and Vaccine Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
10. Equipment and Supplies There were too few ambulances to carry the sick to the hospital, so mules pulled the ambulance carts until the mules, exhausted, stopped working. There were too few sheets for the beds … There were too few beds, so several thousand cots were crammed into every square inch of corridor, storage area, meeting room, office, and veranda. The Great Influenza, John M. Barry
During an influenza pandemic, health care settings will need large quantities of equipment and supplies to provide care and to protect health care workers. Demand will be high worldwide, and traditional supply chains may break down. The health system must take steps to have an adequate stock of equipment and supplies to meet increased patient care needs and to protect health care workers, access to back up supplies, and an efficient system for purchasing, storing and distributing those supplies. In early 2006, the ministry began developing and implementing a comprehensive pandemic procurement strategy to purchase and warehouse critical health care supplies. This strategy includes building:
• a stockpile of personal protective equipment
• a system for purchasing, storing and distributing supplies
• a process to manage perishable supplies. The ministry is currently focused on procuring infection control and mass vaccination supplies. These items are priorities because they provide critical protection for health care workers and their patients and will be in short supply in a pandemic.
Chapter #10: Equipment and Supplies
10.1 Objectives Objectives 1. To maintain in all settings/facilities a four-week stockpile of equipment and supplies for use during a pandemic. 2.
To develop a provincial stockpile to supplement setting/facility stockpiles and provide a source for supplies and equipment when settings run low or if the usual supply chains fail.
3.
To develop an effective system for procuring, storing and distributing equipment and supplies.
10.2 Equipment and Supply Targets To be able to respond effectively to a pandemic and avoid supply chain problems, the Ministry of Health and Long-Term Care is asking all health care settings/providers to plan for and maintain a four-week stockpile of personal protective equipment and other critical supplies. This will give organizations and practices surge capacity and ensure business continuity for the first wave of the pandemic (estimated to be approximately 8 weeks). In addition, the ministry is developing a four-week provincial stockpile of personal protective equipment that organizations will be able to access when/if their individual/local stockpiles are exhausted.
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Ontario Health Plan for an Influenza Pandemic August 2008
The provincial stockpile can be used until regular supply chains can be re-established. To access the ministry stockpile during a pandemic, health care provider organizations should contact the Ministry Emergency Operations Centre at 1-866-2122272. To help smaller clinical settings/ practitioners who may not have the resources to develop adequate stockpiles, the ministry has provided over 15,000 Emergency Infection Control Kits to community health centres, Aboriginal health centres, community physician offices, primary care nurse practitioners, and midwives to provide extra emergency response capacity in smaller clinical settings.
10.3 Planning for Generic Supplies To help organizations estimate their equipment and supply requirements, the ministry has developed templates of generic equipment and supplies required to provide care for people with influenza in the community and in hospital – including personal protective equipment (PPE) and diagnostic equipment and supplies for direct patient care (see Chapter 10A). As OHPIP evolves and the roles of various health care sectors are more clearly defined, the templates will be reviewed and refined. The templates include:
• generic equipment and supplies across health sectors that would either be unavailable or in limited supply during a pandemic
Chapter #10: Equipment and Supplies
• PPE equipment required based on the PIDAC and Ministry of Labour recommendations for infection control and occupational health and safety for influenza. Note: Other PPE will be required to allow some sectors to maintain current routine practices. For example, Emergency Medical Services (EMS) currently employs an “all hazards” approach when responding to an emergency and will maintain that routine practice during a pandemic. High risk environments, such as testing laboratories, will also continue to need PPE appropriate for their activities. For guidance on conducting a risk assessment to determine the type of PPE health care workers need, see Chapter 7.
10.4 Planning for Specialized Equipment In addition to the generic supplies and equipment currently listed on the template, some sectors will require specific or specialized equipment and supplies. For example, public health laboratories have identified requirements for: nucleic acids extractors, liquid handlers (PCR set-up robotic pipettors), real-time thermocyclers, and reagents and disposables (pipette tips, 96 well plates).
10.5 Next Steps Each sector will work with their settings and associations to identify sector-specific equipment and supply needs. The MOHLTC will continue to develop an effective distribution system for equipment and supplies.
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Ontario Health Plan for an Influenza Pandemic August 2008
10A. Supplies and Equipment Tools Contents 1. Supply and Equipment Template: Care at Hospital ........................................................................ 1 2. Supply and Equipment Template: Emergency Medical Services .................................................. 3 3. Supply and Equipment Template: Care in the Community ............................................................ 4
Chapter #10A: Equipment and Supplies Tools
0
Ontario Health Plan for an Influenza Pandemic August 2008
Supply and Equipment Template: Care at Hospital CARE AT HOSPITALS
Equipment and Supplies Category Hand Hygiene
Personal Protective Equipment
Temperature & BP monitoring supplies
Disinfectants
Diagnostics
Cleaning
Injections for pandemic inlfuenza vaccine
Item Liquid soap Alcohol hand rinse Paper towels Surgical/Procedure Masks (for patients) N95 respirators (for HCWs based on risk assessment) Paper gowns (small, medium, large, XL, XXL) Latex exam gloves (small, medium, large, XL, XXL) Non-latex gloves (S,M,L,XL) Safety glasses Thermometers (disposable covers) Stethoscopes Blood Pressure Cuffs (Child, Adult, Large Adult sizes) Disinfecting Wipes Surface cleaner and disinfectant Nasopharyngeal (NP) swab specimen kit: (a) NP swab (b) Viral transport Testing reagents (eg, rapid ELISA-based kits; DFA panels: viral transport media; cell lines and media Garbage bags - clear 20x20 for individual stations Garbage bags Autoclave and other specialized waste disposal bags One-use tissues Needles 25 gage 1", 25 gage 5/8" Syringes Alcohol wipes Sharps containers Medium cotton balls Band-Aids
Chapter #10A: Equipment and Supplies Tools
Triage x x x
ER x x x
Ward x x x
ICU x x x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x x
x x
x x
x x
x
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x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x x
x
Ontario Health Plan for an Influenza Pandemic August 2008
Respiratory Care
Suction
Ice Packs
Paper products Cots or mats Dressing Supplies for Vaccine Injections
IV Products Deceased body management Personal Identification products
Instruction/ info Materials
Forms
Oxygen tubing Oxygen masks – high concentration masks (nonrebreathers) Nasal prongs/cannula Oxygen masks – low oxygen concentration (Simple O2 masks, Venturi masks Oxymeters and probes Portable oxygen tanks with regulators
x
Ventilator supplies Disposable tips, catheters, tubing, canisters Disposable manual resuscitators (BVM) & filters (various sizes) Inline suction catheters Portable suction
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x x
x
x x
x x
x x
x x
x
x
x
Cold Pack sodium or ammonium nitrate Gel pack soft cold pack Paper square absorbent table cover
x x
Sterile Gauze pads (7.6 cm x 7.6 cm)
x
Tape Hypoallergenic 2.5 cm x 9.1 cm Other tapes Solutions Tubing
x x (x) (x)
Body bags ID bands for patients "How to" instruction material for vaccinators "Self-monitor; self-care" info for general public Fact sheets for patients and families Consent forms for vaccines Adverse reaction reporting form Assessment/health record forms
Chapter #10A: Equipment and Supplies Tools
x
Ontario Health Plan for an Influenza Pandemic August 2008
Supply and Equipment Template: Emergency Medical Services (Additional Items specific to EMS)
Face shield Personal Protective Equipment
N95 respirators (various sizes) Tyvex Suits S,M,L,XL,XXL,XXXL
Diagnostics
Monitoring electrodes Disposable linen for 35 A&P stretchers
Cleaning
Respiratory Care Deceased Body Management Forms
Biohazard bags(Yellow) Biohazard boxes for disposal Foil Blankets Osymeters and probes EET tubes with drug port Body bags
Ambulance call reports
Chapter #10A: Equipment and Supplies Tools
Ontario Health Plan for an Influenza Pandemic August 2008
!
Supply and Equipment Template: Care in the Community Equipment and Supplies
Category
Item Liquid Soap Hand Hygiene Alcohol hand rinse Paper towels Surgical/ Procedure Masks (for patients)
N95 Respirators (for healthcare workers) Personal Paper gowns (small, Protective medium, large, XL, Equipment XXL) Latex Exam Gloves (small, medium, large, XL, XXL) Non-latex Gloves (S,M,L,XL) Safety Glasses Thermometers (disposable covers) Temperature & Stethoscopes BP monitoring Blood Pressure Cuffs supplies (Child, Adult, Large Adult sizes) Disinfecting Wipes Disinfectants Surface cleaner and disinfectant Nasopharyngeal (NP) swab specimen kit: (a) NP swab (b) Viral transport Diagnostics Testing reagents (eg, rapid ELISA-based kits; DFA panels: viral transport media; cell lines and media Garbage bags - clear 20x20 for individual stations Garbage bags Cleaning Autoclave and other specialized waste disposal bags One-use tissues
Injections for pandemic inlfuenza vaccine
Testing Laboratories
Independent Practitioners x x x
CHC's x x x
CCAC's
Home Care (Inhome Service Providers)
x
x
x
x
x
x
Community Support Services / Attendant Care LTC Homes x x x x x
X
x
Mortuary Services x x x
Mental Health, Addiction, Other Community Agencies x x x
x
Community Labs x x
Public Health x x x
Hospital Labs x x x
Local PH Units x x x
Mass Prophyl clinics x x x
x
x
x
x
x
x
X
x
x
x
x
x
x
x
x
x
x
x
x
x
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Shelters TBD
x
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x
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x x
x
x
x
x
x
x
x
x
x x x x
x
x
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x
x
x x
x
x x
x
Needles 25 gage 1", 25 gage 5/8" Syringes Alcohol wipes Sharps containers
x
Medium cotton balls Band-Aids
x
Chapter #10A: Equipment and Supplies Tools
x x x x
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Ontario Health Plan for an Influenza Pandemic August 2008 Equipment and Supplies
Category
Respiratory Care
Suction
Item Oxygen tubing Oxygen masks -- high concentration masks (non-rebreathers) Nasal prongs/cannula Oxygen masks -- low oxygen concentration (Simple O2 masks, Venturi masks Oxymeters and probes Portable oxygen tanks with regulators Ventilator supplies Disposable tips, catheters, tubing, canisters Disposable manual resuscitators (BVM) & filters (various sizes)
Testing Laboratories
Independent Practitioners
CHC's
CCAC's
Inline suction catheters Portable suction Cold Pack sodium or ammonium nitrate
Ice Packs
Gel pack soft cold pack Paper square absorbent Paper products table cover Cots or mats Sterile Gauze pads (7.6 Dressing cm x 7.6 cm) Supplies for Tape Hypoallergenic 2.5 Vaccine cm x 9.1 cm Injections Other tapes Solutions IV Products Tubing Deceased body Body bags management Personal Identification products
Home Care (Inhome Service Providers)
Community Support Services / Attendant Care LTC Homes x
Mortuary Services
Mental Health, Addiction, Other Community Agencies
Community Labs
Public Health
Hospital Labs
Local PH Units
Mass Prophyl clinics
x x x x x
x
x
x
x x x x
x x x x x
x x
x x
x
x
ID bands for patients
"How to" instruction material for vaccinators Instruction/ info Materials "Self-monitor; self-care" info for general public Fact sheets for patients and families Consent forms for Vaccines Adverse reaction Forms reporting form Assessment/health record forms
Chapter #10A: Equipment and Supplies Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
11. Influenza Assessment, Treatment and Referral [The community] set up a twenty-four hour telephone bank … newspapers and placards urged people to call “Filbert 100” twenty-four hours a day for information and referrals. It transformed kitchens in public schools—which were closed – into soup kitchens that prepared meals for tens of thousands of people too ill to prepare their own. It divided the city into seven districts and, to conserve physicians’ time, dispatched them according to geography, meaning that doctors did not see their own patients. The Great Influenza, John M. Barry
During an influenza pandemic, Ontarians who develop influenza symptoms must know where to go for assessment, treatment and, if necessary, referral to other services (e.g., hospital, home care). And they must be able to access assessment services quickly. Influenza assessment, treatment and referral services will be provided in the community, by primary care practitioners. This will allow hospitals to focus on treating people who are critically ill with influenza or have other urgent or life-threatening illnesses or injuries. For purposes of OHPIP, primary care practitioners include physicians – including paediatricians who provide primary care, nurse practitioners, nurses and other primary care providers working in family health teams, community health centres, physician practices, nurse practitioner practices, and other primary care agencies. Each community is encouraged to establish a Community Influenza Assessment Committee to plan for influenza assessment and treatment services and oversee the development influenza assessment centres, if required. Membership should include: community-based health care providers, hospitals, public health, municipal emergency management services, municipal public works, policing services, and the volunteer sector.
11.1 Objectives • To provide timely access to influenza assessment, treatment and referral services.
• To treat people diagnosed with influenza and prescribe antivirals within recommended time frames.
• To identify and refer people who need hospital, home care or other communitybased services.
• To maintain essential (i.e., nondeferrable) primary services during a pandemic.
• To contribute to the prevention and control of pandemic influenza.
• To instil public confidence in the influenza services available to them.
11.2 Principles Guiding Influenza Assessment, Treatment and Referral In addition to the assumptions identified in chapter 3, the proposed approach to community-based influenza assessment, treatment and referral is based on the following principles:
• The public will need support and information to understand how to access the health care system.
• All Ontarians should be able to access influenza care quickly, including those
Chapter #11: Influenza Assessment, Treatment and Referral
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Ontario Health Plan for an Influenza Pandemic August 2008
who do not have a regular primary care practitioner.
• Antiviral therapy should be started as soon as possible after onset of symptoms, ideally within 12 to 24 hours. Antiviral therapy should not be started more than 48 hours after onset of symptoms because it is ineffective in most patients.
• As far as possible, Ontario will use the existing primary care system – including Telehealth, family health teams, physicians, community health centres, walk-in clinics and pharmacies – to provide integrated, streamlined influenza-related primary care (i.e., assessment, treatment and referral services).
• Primary care offices may change booking patterns in order to meet needs, and patients may not be seen by their own provider.
• During the assessment process, every effort will be made to separate people with influenza symptoms from other primary care patients, and to use other infection control measures, such as hand hygiene.
• Communities will plan for alternative ways to provide assessment, treatment and referral services – such as dedicated influenza assessment and treatment centres (Flu Centres) – in the event that the existing primary care system becomes overwhelmed due to the severity of the pandemic.
11.3 Assessment Diagnosing pandemic influenza will be challenging – particularly given that diagnosis will have to be made early in the course of the illness for antivirals to be effective. Influenza usually has a sudden severe onset, but not all presentations will
be classical and it may be difficult for both the public and primary care providers to differentiate pandemic influenza from other illnesses. Ontarians will have three possible pathways for influenza assessment:
• a self-assessment that individuals can do themselves
• a screening that health care providers can do with individuals by phone
• a face-to-face assessment done by a primary care provider. Messages to the public at the time of a pandemic will encourage them to self-assess and call Telehealth or their family physician before seeking a face-to-face assessment. Self-Assessment To assist Ontarians with self-assessment, the MOHLTC has developed a self-assessment tool for the public, which will be posted on the ministry web site and widely publicized (see Chapter 11A). Note: the self-assessment tool will be updated at the time of a pandemic to reflect the epidemiology of the pandemic strain of the virus. Individuals will use the self-assessment tool to determine whether they can manage their symptoms at home (self-care) or whether they require further assessment or advice. Telephone Screening Individuals will be able to access remote screening for influenza by calling Telehealth, the municipal call centre (if available), or their primary care provider. To ensure a consistent approach to telephone screening across the province, primary care providers will be encouraged to use the same screening questions as on the self-assessment tool (see Chapter 11A) unless directed otherwise at the time of the pandemic, and lab testing will be limited.
Chapter #11: Influenza Assessment, Treatment and Referral
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Ontario Health Plan for an Influenza Pandemic August 2008
Based on the results of telephone screening, health care providers will refer individuals to the appropriate level of care (i.e., self-care at home, a face-to-face assessment by a primary care provider, or the nearest hospital emergency department), or they may be able to prescribe antivirals over the phone. Face-to-Face Assessment People who require further assessment or treatment will be advised to see their primary care provider (or, depending on the severity of the pandemic, to go to an alternative site such as a Flu Centre) for a
face-to-face assessment using the Primary Assessment Record (see Chapter 11A). Ontarians receiving an influenza assessment in a hospital, long-term care home, or other facility or by a home care provider should also be assessed using the Primary Assessment Record (see Chapter 11A). Figure 11.1 illustrates the common approach to influenza screening and referral that will be used by all health care services.
Figure 11.1: Common Approach to Influenza Screening and Referral
Chapter #11: Influenza Assessment, Treatment and Referral
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Ontario Health Plan for an Influenza Pandemic August 2008
Note: patients who are screened in an established health care institution (e.g., hospitals, long-term care homes) will be treated where they are or referred to a more appropriate care setting (e.g., hospital). Once assessed, individuals will be assigned to one of four categories (see Table 11.1) and either treated in place (i.e., by their primary care provider, at a Flu Centre or in their care setting) or referred to the appropriate level and site for care. Services for Vulnerable Ontarians There are two groups of Ontarians who may have difficulty accessing influenza assessment services through the existing primary care system:
• Ontarians who do not have a regular primary care provider and rely on walkin clinics or emergency departments for their care. The local health care system should include this group in their planning for services during an influenza pandemic
• vulnerable Ontarians, such as people who are shut in, living in shelters, on the street or otherwise marginalized. The MOHLTC, the Ministry of Community and Social Services, and local social service providers are developing a strategy to support vulnerable Ontarians and help ensure timely access to influenza assessment services.
11.4 Prescribing Antivirals Timing of Antiviral Treatment Ontario will have a large enough supply of antivirals to treat everyone who requires treatment. Antivirals should be started as soon as possible after onset of symptoms: ideally within 12 to 24 hours. Antivirals should not be prescribed after 48 hours because they are not effective in most patients. For treatment guidelines for influenza, see Chapter 11A.
Table 11.1: Influenza Assessment Categories Assessment Category
Referral
1. No influenza-like illness identified
No treatment required. Offer educational material on influenza.
2. Further assessment required to make a diagnosis
Consider initiating treatment.
3. Influenza-like illness identified
Initiate treatment.
Refer for diagnostic work-up including radiological examinations and/or laboratory testing (see Chapter 14 for laboratory tests available by phase, recommended tests, obtaining proper specimens).
Assess for appropriate discharge/referral (i.e., to self-care at home, to home with community supports). Follow up with vulnerable patients in 24 to 48 hours to assess status. 4. Influenza-like illness identified, high risk criteria identified
Transfer to hospital for assessment.
Chapter #11: Influenza Assessment, Treatment and Referral
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Ontario Health Plan for an Influenza Pandemic August 2008
Access to Antivirals Antivirals prescribed by primary care practitioners will be distributed through pharmacies, which already have secure systems for storing medications. Pharmacies will also be responsible for tracking who receives antivirals and the quantities of antivirals dispensed. As part of pandemic planning, local planners and/or primary care practitioners should work with local pharmacies to plan for adequate supplies of antivirals.
11.6 Maintaining Primary Care Services During a Pandemic During the peak period of an influenza pandemic, primary care practitioners and office staff may develop influenza or have to care for family members who are ill and may be unavailable to work for a period of time. To be able to provide influenza assessment and treatment services as well as other essential (i.e., non-deferrable) primary care services during a pandemic, primary care providers may consider using the following strategies:
Antivirals for influenza assessment, treatment and referral centres will be coordinated and distributed centrally by the Ministry of Health and Long-Term Care to ensure security of the supply chain and effective tracking. The Flu Centres will be responsible for maintaining records on who receives antivirals and the quantities dispensed.
1.
Deliver services in different ways
2.
Defer some services
3.
Deliver new services or work in Flu Centres
4.
Develop plans to ensure continuity of care, with particular attention to vulnerable patients/patients with ongoing health problems
11.5 Supplies and Equipment
5.
Use appropriate occupational health and safety/infection prevention and
Like other parts of the health care system, primary care practices and physician offices are expected to maintain a fourweek stockpile of supplies and equipment. The ministry has provided Emergency Infection Control Kits to communitybased physicians, nurse practitioners and midwives, which contain a 10-day supply of some infection control supplies and equipment. The kits are considered part of the four-week supply that each practice/office must maintain. The MOHLTC will also maintain an additional four-week supply for primary care providers. For more information on supplies and equipment, see Chapter 10 and 10A.
Chapter 11: Influenza Assessment, Treatment and Referral
Emergency Infection Control Kits To ensure that primary care providers have the supplies required to protect staff and patients, the Ministry of Health and Long-Term Care has supplied all primary care practices and community health centres with an emergency infection control kit that includes a supply of: hand sanitizer surgical masks gloves eye protection disposable gowns surface cleaner disinfectant wipes information sheets that can be posted in the office or clinic.
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Ontario Health Plan for an Influenza Pandemic August 2008
control practices. (See Chapter 7; see also Infection Control in the Physician’s Office, the College of Physicians and Surgeons of Ontario, 2004.) 6.
Establish links with other primary care providers
7.
Be aware of the community’s pandemic plan
8.
Develop a plan to communicate effectively with patients
9.
Develop a plan to communicate effectively with staff
10.
Maintain an up-to-date business continuity/emergency plan (see Chapter 11A for a business continuity checklist).
Table 11.2 lists the steps that primary care practices can take during the pandemic alert period and the pandemic period to maintain critical services. For more information on the WHO pandemic periods, see Chapter 2, Table 2.1.
Table 11.2: Potential Actions to Maintain Critical Primary Care Services by Pandemic Period Strategy
Deliver services in different ways
Defer some services
Deliver new services Develop plans to ensure continuity of care for all patients, including vulnerable patients
Use appropriate occupational health
Actions During the Pandemic Alert Period (phases 3 to 5, before pandemic influenza is in your community)
Actions During the Pandemic Period (phase 6, when pandemic influenza is in your community)
• Identify the types of services that could be delivered by phone (e.g., counselling, some assessment services) • Identify the types of prescription medications that can be renewed without having the patient come into the office • Take an inventory of your staff’s competencies to identify services that could be delegated to other providers/staff members who have the competencies to provide them. See the CPSO Delegation of Controlled Acts policy (http://www.cpso.on.ca/policies/ delegation.htm) for more information. • Identify those primary care services that can safely be reduced or deferred during a pandemic (see Table 11.3) • See the laboratory/diagnostic services that will be reduced or suspended during a pandemic (see Chapter 14, Table 14.2) • Learn how to access information from your public health unit during an emergency (i.e., how can you get on their distribution list). • Take into account the services that local hospitals plan to defer (e.g., outpatient clinics, nonessential referrals, elective surgeries). • Take into account the new services that you may have to take on during a pandemic (e.g., services currently provided in hospital). • Maintain a list of vulnerable patients (e.g., people who live alone, people who are handicapped, people who require ongoing monitoring for a health condition, frail elderly) • Identify strategies to meet their needs during a pandemic (e.g., regular phone contact, having them move in with a family member, home blood pressure monitoring, referring them to a community service if available)
• Provide as much care and advice as is safely possible by phone. • Consider home visits to patients whose health might be compromised by coming into the office. • Work within Delegation of Controlled Acts policy to delegate tasks.
Practitioner as employer • Be familiar with recommended occupational
Practitioner as employer • Reinforce training, hand hygiene
Chapter 11: Influenza Assessment, Treatment and Referral
• Decide which services to defer – and the length of the deferment – based on the severity of the pandemic, and triage patients accordingly • Access information in real time from the local medical officer of health about the severity of the pandemic in your region and how to handle services • Do not send patients to the hospital for non-essential services. • Implement plan. • Implement plan
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Ontario Health Plan for an Influenza Pandemic August 2008 Strategy
and safety/infection prevention and control practices
Establish links with other primary care providers
Be part of the community’s pandemic plan
Actions During the Pandemic Alert Period (phases 3 to 5, before pandemic influenza is in your community)
Actions During the Pandemic Period (phase 6, when pandemic influenza is in your community)
health and safety/infection prevention and control practices (see Chapter 7) • Be aware of your responsibilities under the Occupational Health and Safety Act (e.g., train workers, provide appropriate personal protective equipment) • Engineering controls: Make changes to the physical environment (if possible) to reduce the spread of influenza • Administrative/Work Practices: Recommend annual influenza immunization for all staff; place alcohol-based hand rub at the point of care; ask coughing patients to wear a surgical mask in the waiting room; have a separate area for ILI patients; schedule patients so that you only see ILI patients at a certain time during the day (e.g., non-ILI patients in the morning and ILI patients in the afternoon); conduct telephone triage to divert patients to appropriate level of care; erect plexiglass barriers between receptionists and clients; cohort patients in the waiting area • Develop policies to encourage staff to stay home when they are sick • Personal Protective Equipment: Determine the type of personal protective equipment required for all staff based on the job that they perform (see risk assessment in Chapter 7) • Ensure you have received your emergency infection control kit from the MOHLTC • Establish fit testing program for staff who require (based on the risk assessment) N95 respirators (phase 5). See Chapter 7A for a list of organizations that can assist with fit testing. • Maintain a four-week stockpile of personal protective equipment (MOHLTC will also maintain a four-week stockpile. To access this stockpile, contact the Ministry Emergency Operations Centre at 1-866-212-2272.) • Use MOHLTC training materials to provide general training/information for staff Practitioner as employee • Be familiar with recommended occupational health and safety/infection prevention and control practices (Chapter 7) • Participate in risk assessment and training • Establish links with other primary care practitioners and make arrangements to provide coverage for one another in the event of staff shortages during a pandemic • Identify opportunities to collaborate/share resources (e.g., sharing responsibility for staffing a patient call line, collaborating to reduce costs associated with fit testing of N95 masks, designating one site for influenza assessment and another for other patients) • Ensure the local public health unit, the MOHLTC and your professional college and association have your up-to-date contact information so you will receive information and directives during a pandemic • Be aware of the resources (website, tools, subcommittees) available from the local public health unit and how to access them during a pandemic • Identify issues that should be addressed in the local plan in order to maintain primary care services (e.g., access to child care and elder care
policies and procedures, cough etiquette, and use of personal protective equipment • Use the screening tool provided by the MOHLTC to screen patients for flu symptoms, and implement appropriate precautions (e.g., referring patients to a Flu Centre, asking patients to wear a surgical mask in the waiting area). The ministry will provide all health settings with a common screening tool when the characteristics of the pandemic strain are known • Use the same screening tool to screen staff for flu symptoms and implement appropriate workplace practices (i.e., ask staff to go home if they are sick) • Clean more frequently and follow environmental guidelines for cleaning (see Chapter 7) • Access ministry equipment stockpiles when necessary • In the event that supplies of equipment such as N95 or comparable respirators run out, provide surgical masks Practitioner as employee
Chapter 11: Influenza Assessment, Treatment and Referral
• Follow recommended practices, including appropriate use of personal protective equipment
• Work collaboratively to maintain essential primary care services and provide care for people with influenza
• Implement role in the plan
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Communicate with patients
Communicate with staff
Maintain business continuity plans
Actions During the Pandemic Alert Period (phases 3 to 5, before pandemic influenza is in your community) services) • Negotiate arrangements to provide services in Flu Centres (if established), long-term care homes or other settings, if required • Maintain an up-to-date list of patient contact information • Tell patients how office and care practices will change during a pandemic (e.g., more care provided by phone, the use of Flu Centres in communities that establish them). See tools section for a sample handout describing the changes. • Give patients information about how to protect themselves from flu and how to care for family members who fall ill. The ministry has developed a series of fact sheets in 23 languages. During the pandemic alert period (phase 5), the ministry will distribute a supply of these fact sheets to all primary care practices, along with information on how to order more. • Explore services, such as mass emails or reverse 911, which will automatically send a phone message to all your patients • Maintain an up-to-date list of all staff contact information • Inform staff about the plans to maintain services during a pandemic • Consult with and inform Joint Health and Safety Committee/representative • Use ministry fact sheets to provide information on influenza, occupational health and safety/infection prevention and control • Review and update your business continuity plan. See tools for business continuity checklist
11.7 Guide to Deferring Primary Care Services Depending on the severity of the pandemic, primary care practitioners may have to delay or defer some services in order to meet the demand for influenza assessment and treatment services, and to care for patients with other urgent needs. Table 11.3 provides criteria that practitioners can use to decide which services they will delay or defer. Some of
Actions During the Pandemic Period (phase 6, when pandemic influenza is in your community)
• Use messages on answering machines and signs on doors to advise patients to call the office or Telehealth, rather than coming in. • Walk-in and after hours clinics should post signs advising people to phone to determine whether they should come into the clinic or go elsewhere for assessment and care. • Put information about the services that will be deferred during the pandemic on the answering machine, on the door and in offices. • Use information provided by the ministry (e.g., fact sheets) to ensure patients/the public receive a consistent message • Update staff each day • Use information provided by the MOHLTC (e.g., Important Health Notices, directives) to ensure staff receive consistent messages
• Implement business continuity plan
these decisions will be influenced by other parts of the health care system. For example, if laboratories have temporarily suspended cholesterol testing and other preventive testing, then primary care practitioners will not be able to provide these services. Note: the possible deferrable services are examples only and clinicians should use their judgement. For example, for clients who need to access disability pensions, completing forms may not be deferrable.
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Table 11.3: Examples of Primary Care Needs that Can or Cannot be Deferred
Priority
Description
Examples
Priority A
Patients who have urgent needs and require services/treatment and would otherwise have to go to a hospital for care
Patients whose situation is noncritical and who require treatment/services that can be deferred for a few weeks (i.e., during the peak of the pandemic wave)
• Acute exacerbation of a chronic illness that doesn’t require hospitalization • Complications of pregnancy • Certain acute infections, such as otitis, UTI, cellulitis, STIs • Acute major illness/injury • Acute minor injuries (e.g. lacerations) • Acute psychiatric illness • Abdominal pain NYD • Musculoskeletal pain • Headache • Palliative care • Patients recently discharged from hospital on new medication who must be followed closely (e.g., warfarin) • Patients requiring pneumococcal immunization • Stable chronic disease management, including asthma, diabetes, hypertension, and stable cardiac, pulmonary, renal, neurological or hepatic disease • Uncomplicated pregnancy care – 1st or 2nd trimester • Well baby visit • Routine childhood immunization
Patients whose condition is nonlife threatening and who require services that can either be deferred or managed in another way (e.g., automatic prescriptions) for the duration of a pandemic
• • • • • •
Essential preventive services
Priority B
Priority C
11.8 Access to Information During a Pandemic During an influenza pandemic, MOHLTC will be the lead point of access for health information at the provincial level. To help primary care practitioners monitor and assess their capacity to meet demand for services, the MOHLTC will provide daily information on the number of influenza cases in communities across Ontario, and on the epidemiology of the virus (i.e., symptoms, people most vulnerable). Local medical officers of health will provide direction on the role of primary care in their health unit areas. (See Chapter 5: Surveillance.) During a pandemic, the Ministry of Health and Long-Term Care may issue directives about care, infection control or other issues. Information will be provided on how and when to apply these directives in primary
Chapter 11: Influenza Assessment, Treatment and Referral
Well child and adult checkups Nutrition and weight counselling Pap smears Routine adult immunization Preventive services and clinics Insurance and other forms
care settings. Under the Health Protection and Promotion Act, primary Note: OHPIP recommends using the hierarchy of controls approach (see care practitionChapter 7) to occupational health ers are required and safety/infection prevention and control, which includes to comply with environmental controls and administrative/work practices that directives issued reduce the spread of disease, as well by the Chief as the use of personal protective equipment. The type and level of Medical Officer controls vary depending on the of Health. nature of the setting and type of care being provided.
In addition, the Ministry Emergency Operations Centre will:
• maintain up-to-date information on the ministry web site and on www.ehealthontario.ca
• send regular email or fax updates to practitioners. To register for this service, visit www.publichealthontario.ca and click on the “Public Health Notification
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Intake Form” button on the right-hand menu.
• provide a call centre for primary care practitioners who want information on appropriate procedures and protocols. Note: during a pandemic the hotline number will be posted on the ministry’s web site or accessed by calling 1-866-8017242. Information will also be available from the professional associations and colleges. Primary care practitioners should contact their professional association to learn how they will communicate with members during a pandemic. More information on healthcare provider communications during a pandemic is available in Chapter 12.
11.9 Criteria for Activating Alternative Approach to Assessment During a mild to moderate influenza pandemic, existing primary care services should have the capacity to provide influenza assessment, treatment and referral services – and continue to provide the other primary care services that Ontarians will need. However, during a moderate to severe pandemic, primary care services may become overwhelmed, and communities may need an alternative approach, such as establishing dedicated Flu Centres or directing people to designated primary care services rather than to their own primary care provider. The trigger for switching to an alternative approach will be when the existing primary care system is no longer able to ensure that patients are assessed, diagnosed and treated with antivirals within 12 to 24 hours of developing symptoms. The lead agency at the local level
Chapter 11: Influenza Assessment, Treatment and Referral
responsible for implementing the early antiviral treatment strategy within the public health unit catchment area will need to plan for the full range of activities including the potential need for Flu Centres in the event of a moderate to severe pandemic. For guidelines on how to plan a Flu Centre, see Chapter 11A.
11.10 Planning for Flu Centres In the event that a severe pandemic overwhelms existing primary care services, communities will need to plan for alternative ways to provide assessment, treatment and referral services, such as dedicated Flu Centres. Flu Centres will be temporary additions to the health care delivery system, and will be planned and managed locally. Lead Agencies Because communities are in the best position to determine how to meet their planning needs, the lead agency designated to oversee planning for influenza assessment services including implementation of Flu Centre/s shall be identified locally. For those communities that are unable to identify a lead agency to coordinate planning, the MOHLTC will designate one. The Community Influenza Assessment Committee will support the lead agency in planning to implement each Flu Centre, identifying the groups/organizations in the community best positioned to manage Flu Centres once they are opened. Access to Assessment and Treatment To encourage the public to use the Flu Centres, the centres will not require people to have a Health Card for assessment and treatment. These services will be available at no cost to the patients. The Flu Centres will use unique identifiers to track patients.
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Treatment at the Flu Centres Treatment available at the Flu Centres will include the following:
• supportive care strategies to ease symptoms
• access to antiviral drugs and associated therapeutics in accordance with clinical guidelines as provided at the time of the pandemic
• education about transmission and possible complications. Documentation To streamline the assessment and treatment process, all settings will use the Primary Assessment Record (see Chapter 11A: Influenza Assessment, Treatment and Referral Centre Tools) for the initial assessment and treatment. The Primary Assessment Record will accompany the patient through the Flu Centre and to other treatment sites if required. For patients who have to be admitted to hospital, the hospitals will use the Primary Assessment Record (see Chapter 11A: Influenza Assessment, Treatment and Referral Centre Tools) as well as the Secondary Assessment for Hospital and the Influenza Admission form (see Chapter 17: Acute Care Services). These forms can be downloaded from the Ministry of Health and Long-Term Care website at: www.health.gov.on.ca/pandemic. A detailed guideline on planning for the implementation of Flu Centres is available in Chapter 11A. Deployment of Primary Care Providers In the event that communities decide to use alternative approaches to assessment, some primary care practitioners may be asked to work at least part time or provide assistance in other settings, such as Flu Centres,
Chapter 11: Influenza Assessment, Treatment and Referral
hospitals, long-term care homes and home care. Because influenza is primarily a community-acquired infection, there will be no restrictions on where primary care practitioners can work during a pandemic.
11.11 Next Steps To address issues that may affect the provision of primary care and influenza assessment, treatment and referral during a pandemic, MOHLTC will:
• continue to refine the self-assessment tools
• adapt the self-assessment tool for use by Telehealth and in telephone assessment
• develop a decision support tool for primary care practitioners
• develop communications products for primary care providers and a dissemination strategy
• develop guidelines on the use of pharmacies to distribute antivirals to the public
• consult with other parts of government about deferring the need for medical signatures on administrative forms as well as limitations on drug renewals
• address regulatory and other issues that may affect access to primary care, including personal liability insurance, licensing and scope of practice issues, the use of medical directives and temporary licenses, and financial compensation for primary care practitioners who work in alternative sites, such as Flu Centres.
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11A: Influenza Assessment, Treatment and Referral Tools Contents: Adult Influenza Self-Assessment Tool.................................................................................................... 1 Primary Assessment Record – Adult ...................................................................................................... 2 Pandemic Preparedness Checklist for Primary Care Practices and Practitioners ............................ 8 Guidelines for Developing Influenza Assessment, Treatment and Referral Centres .................... 11 1. Introduction------------------------------------------------------------------------------------ 11 2. Function of a Flu Centre Centre ---------------------------------------------------------- 11 3. Organizing, Structure and Funding of Flu Centres ---------------------------------- 12 4. Developing Flu Centres--------------------------------------------------------------------- 14 5. Criteria for Opening a Flu Centre -------------------------------------------------------- 20 6. Site Management ----------------------------------------------------------------------------- 20 7. Staff Requirements --------------------------------------------------------------------------- 21 8. Infection Prevention and Control Measures ------------------------------------------- 27 9. Clinical Management ------------------------------------------------------------------------ 27 10. Security and Traffic Control-------------------------------------------------------------- 28 11. Overnight Service and Stays ------------------------------------------------------------- 28 Transfer Protocol from Flu Centre to an Acute Care Facility ............................................................ 32
Ontario Health Plan for an Influenza Pandemic August 2008
DRAFT Adult Influenza Self Assessment Tool (in development)
Chapter #11A: Influenza Assessment, Treatment and Referral Tools
11A- 1
Ontario Health Plan for an Influenza Pandemic August 2008 Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
This patient may have influenza! (hand hygiene, gloves, eye protection, N95 respirator, and gown if close contact).
Primary Assessment Record - Adult Patient (first name, last name) please print
Date (dd/mm/yy)
/
Time (hh : mm)
/
:
Section 1 - History Check all that applies below and give dates when symptoms started a.
General
When? (dd/mm/yyyy) o
/ / /
/ / /
Stiffness
/ /
/ /
Weakness
/
/
Red and/or watery eyes
/ /
/ /
Fever ( >38 C ) Chills Headache Aching muscles and joints
Earache b.
Respiratory
/
/
Sore throat
/ / / /
/ / / /
/
/
Hoarseness Stuffy or runny nose Shortness of breath Chest pain when taking a deep breath
Digestive
When? (dd/mm/yyyy)
/ / /
Vomiting Diarrhea Abdominal pain d.
e.
When? (dd/mm/yyyy)
Cough
c.
Neurological
/ / /
When? (dd/mm/yyyy)
Confusion, drowsiness
/
/
Convulsions
/
/
Contact
When? (dd/mm/yyyy)
Have you had contact with someone with similar symptoms? no
/
/
yes, when?
Section 2 - Allergies 1. 2. 3.
Reaction: Reaction: Reaction:
Section 3 - Medications Do you take any medication (pills, inhalers, needles, etc) on a regular basis? no yes, please complete the Medication List. Signature of Patient
Date (dd/mm/yyyy)
/ If completed by someone other than patient Name (first name, last name) please print
/
Signature
4433-45 (07/05)
Chapter #11A: Influenza Assessment, Treatment and Referral Tools
Ministry of Health and Long-Term Care
11A- 2
Ontario Health Plan for an Influenza Pandemic August 2008 Name of patient: Address:
/
Date of birth:
/
Age:
MRN Telephone:
Home: (
)
-
Business: (
)
-
Section 3 - Medications continued … 1. Allergies I am allergic to: 2. Medications Please list the medications you take, including the following: (the dose, how often you take it, and how you have to take it (pill, injection, etc)).
Medication List Drug (medication name, dose, route, frequency)
To be continued in hospital yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
3. Signature of Patient or person completing this form
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Chapter #11A: Influenza Assessment, Treatment and Referral Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient: Address:
/
Date of birth:
/
Age:
MRN Telephone:
Home: (
)
-
Business: (
)
-
Section 4 - Assessment Clinical Case Definition When influenza is circulating in the community, the presence of fever and cough of acute onset are good predictors of influenza. The positive predictive value increases when fever is higher than 380C and when the onset of clinical illness is acute (less 48 hours after the prodromes). Other symptoms, such as sore throat, rhinorrhea, malaise, rigors or chills, myalgia and headache may also be present. Any case definitions developed prior to the pandemic may need to be modified once the pandemic occurs. A history of contact with another patient with influenza-like illness or with an influenza case confirmed by the laboratory should be sought. If present, it is of diagnostic value. Heart Rate: _________ /min
Is HR > 100/min?
no
yes
Resp Rate: _________ /min
Is RR > 24/min?
no
yes
Blood Pressure ____ / ___ mmHg
Is systolic BP < 100 mmHg?
no
yes
o
0
Temperature: _______ C
T>38 C?
no
yes
SpO2: _____________ %
Is SpO2 ! 90%?
no
yes
Mucous Membranes:
Are lips/nail beds cyanotic?
no
yes
Chest auscultation:
Are crackles present?
no
yes
Mental status:
Is patient confused?
no
yes
Chest pain:
Does patient have chest pain?
no
yes
Vomiting:
Is patient vomiting > 3x’s/24h?
no
yes
If all “no” boxes are checked, go to Section 5. If any “yes” boxes are checked, go to Section 6a. If patient meets any of the following criteria, apply oxygen to maintain a SpO2 > 90% and notify MD immediately: (check all that apply) SpO2 ! 90%
Inability to protect airway
RR > 30/min
Clinical evidence of severe respiratory distress or impending respiratory failure
Systolic BP < 90mmHg
HR < 40/min or > 120/min
Did this patient’s influenza symptoms start within the last 48 hours? no, complete section 5, Discharge with telephone Follow-up. yes, complete section 6 4433-45 (07/05)
Chapter #11A: Influenza Assessment, Treatment and Referral Tools
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008 Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Patient (first name, last name) please print
Section 5 - Discharge Assessment check all that apply Age > 65 years
pregnancy
Chronic lung disease
congestive heart failure
renal failure/dialysis
immunosuppression
haematological/blood abnormalities
diabetes
hepatic/liver disease
If any boxes are checked, discharge home with telephone follow up in 48 hours Self care instruction sheet provided and reviewed Discharge instruction sheet provided and reviewed
Discharge date (dd/mm/yyyy)
/
/
Discharge time (hh : mm)
:
Prescription provided (see Section 6 “Orders”) Assessor’s (first name, last name) please print
Assessor’s Designation
Assessor’s signature
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Chapter #11A: Influenza Assessment, Treatment and Referral Tools
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008 Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Home: (
Telephone:
)
-
Business: (
)
-
Patient (first name, last name) please print
Section 6 a - Orders Discharge date (dd/mm/yyyy)
Orders
Discharge time (hh : mm)
Discharge home on self-care with self-care instructions
/
/
:
Discharge home with telephone follow-up in 48 hours.
/
/
:
/
/
:
/
/
:
/
/
:
Follow-up booked Discharge to hospital for Secondary Assessment. Transfer arranged PAR sent with patient
/
/
:
Diagnostic testing ordered
/
/
:
Section 6 b - Prescriptions First dose given of oseltamivir
oseltamivir 75mg PO bid x 5 days (oseltamivir is recommended as first line treatment for all patients, except if on dialysis or pregnant or breastfeeding)
Time (hh:mm)
Assessor’s initials
:
OR zanamivir 10 mg ( 2 inhalations) bid x 5 days (recommended if on dialysis or if pregnant or breastfeeding).
First dose given of zanamivir
Warning: zanamivir is not recommended for patients with asthma or COPD
Time (hh:mm)
Assessor’s initials
:
medication provided Number of doses:
Date (dd/mm/yyyy)
/
Time (hh:mm)
/
:
Physician’s name (first name, last name) please print
CPSO Number
Physician’s signature
Date (dd/mm/yyyy)
/ Original Prescription (this page): Patient
Assessor’s initials
/
Copy/duplicate : Patient chart
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Chapter #11A: Influenza Assessment, Treatment and Referral Tools
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008 Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Patient (first name, last name) please print
Section 7 – Lab Orders Please order the following: 1.
CBC, K+, Na+, CI-, HC03, Cr, Ur, glucose, AST, ALT, ALP, Tbili, CK
2.
EKG & troponin if history of chest pain or cardiac disease
3.
CXR (PA & lat) if SOB or cough or SpO2 < 95% or crackles on chest auscultation
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Pandemic Preparedness Checklist for Primary Care Practices and Practitioners Task/Activity
Yes/No
N/A
Next Steps
1. Planning 1.1 Has the practice/agency or its landlord developed an emergency or disaster plan to ensure continuity of services in the event that community services are disrupted (e.g., lack of water, hydro, food, natural gas, transportation systems)? 1.2 Are emergency/continuity plans reviewed/updated regularly? 1.3 Does the business continuity plan include strategies to maintain access to pharmaceuticals during an emergency (e.g., plans to ensure that pharmaceuticals that require refrigeration can be maintained at an appropriate temperature, arrangements with a local pharmacist to ensure an ongoing supply of commonly used medications)? 1.4. Does the practice/agency have a plan for responding to an influenza pandemic? 1.5 Is the plan reviewed/updated regularly? 1.6 Is the practice/agency aware of/involved in pandemic planning with other health care organizations in the community (e.g., local public health unit, other primary care practices/community agencies, emergency medical services, acute care hospitals, long-term care homes, transportation services)? 1.7 Does the local pandemic influenza plan include criteria to determine where and how people will be cared for in the event of a pandemic?
2. Chain of Command/Command Centre 2.1 Has the practice/agency identified the person responsible for implementing the pandemic plan, and who will take over if that person falls ill (i.e., chain of command)? 2.2 Are all practitioners/staff aware of their roles/responsibilities during a pandemic outbreak? 2.3 Is there a designated area where staff can obtain information on directives or other information related to a pandemic? 2.4. Does the practice/agency have someone responsible for ensuring it fulfills its requirements under the Occupational Health and Safety Act?
3. Maintaining Essential Services 3.1 Has the practice/agency identified essential primary care services that must be maintained during a pandemic? 3.2 Has the practice/agency identified primary care services that could be deferred? 3.3 Does the practice/agency maintain a list of patients who might be vulnerable during a pandemic and need support (e.g., people who live alone, people with complex medical needs)? 3.4 Has the practice/agency identified plans to support vulnerable patients during a pandemic?
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4. Supply Chains 4.1 Has the practice/agency identified the supplies including cleaning supplies and personal protective equipment required during an influenza pandemic? (See Chapter 10 for supplies template) 4.2 Has the practice/agency developed a four-week stockpile of supplies and equipment? 4.3 Will the practice’s usual suppliers be able to fulfill contracts during an influenza pandemic? If not, does the practice/agency have a back-up source of supply?
5. Human Resources 5.1 Does the practice/agency have a staffing contingency plan to cope with staff absences during a pandemic? (e.g., delegating tasks, using administrative staff to provide some services, sharing staff with other primary care practices)? 5.2 Does the practice’s/agency’s plan include strategies to support primary care providers during a pandemic (e.g., child care, transportation, psychosocial support, meals, accommodation, assistance with pet care)? 5.3 Does the practice/agency have a plan to ensure staff continue to be paid during a pandemic? 5.4 Do key practitioners/staff have personal disability insurance?
6. Education and Training 6.1 Has the practice/agency conducted a risk assessment for all staff to determine their need for personal protective equipment? 6.2 Does the practice/agency provide ongoing pandemic training and education, including the donning and removal of personal protective equipment? 6.3 Has the practice/agency arranged for fit testing for practitioners/staff who, based on the type of contact they have with influenza patients, have to wear N95 respirators? 6.4 Does the pandemic plan specify who is responsible for the training program? 6.5 Does the practice/agency include its pandemic plan/pandemic education material in staff orientation programs?
7. Communications 7.1 Is the practice/agency on the ministry’s and the local health unit’s distribution list for information about a pandemic? 7.2 Does the practice/agency provide culturally appropriate and accessible information/education for patients about preventing and treating influenza? (See MOHLTC website for resources) 7.3 Does the practice/agency have a plan for communicating with staff and patients during a pandemic (e.g., phone messages instructing them where to go for care and information)?
8. Prevention 8.1 Does the practice/agency promote annual influenza immunization of staff and patients/clients?
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8.2 Does the practice/agency actively promote hand hygiene and cough etiquette? 8.3 Do staff and patients have easy access to adequate amounts of alcohol-based hand rub, soap, paper towels, and disposable tissues? 8.4 Are the practice/agency’s cleaning practices consistent with best practices? 8.5 Does the practice/agency routinely assess patients/clients for febrile respiratory infection (FRI) and/or influenza-like illness (ILI) ? 8.6 Has the practice/agency identified any changes to the physical environment (i.e., engineering controls) that could reduce the spread of influenza? 8.7 Has the practice/agency identified any changes to practices and procedures (i.e., administrative practices) that could reduce the spread of influenza? 8.8 Does the practice/agency encourage staff to report FRI or ILI symptoms?
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Guidelines for Developing Influenza Assessment, Treatment and Referral Centres (Flu Centres) 1.
Introduction
During a pandemic, about 35% of the population could develop influenza. Based on a 35% attack rate, between 1.8 and 3.4 million Ontarians may be sick enough to require an outpatient visit, and between 25,000 and 83,000 may have to be hospitalized. Existing health care services will be able to meet some of the demand for influenza-related care, but communities may have to develop innovative ways to provide care and keep the health care system from being overwhelmed. If the pandemic becomes severe enough to overwhelm the capacity of existing primary care services to assess patients and provide antiviral treatment within 12 to 24 hours of the onset of symptoms, communities will need an alternative way to delivery influenza assessment, treatment and referral services. In some communities, establishing temporary community-based Influenza Assessment, Treatment and Referral Centres (Flu Centres) may give the public easier access to influenza services and reduce some of the pressure on existing services. These guidelines will help communities plan and implement Flu Centres and should be adapted to meet local needs. Communities that have already developed a plan to respond to the increased demand for health care services during a pandemic should use their existing plan. Note: These guidelines are for Flu Centres that would provide services 18 hours a day; however, section 10 (Overnight Service/Stays) provides information for communities considering Flu Centres that have the capacity to operate 24/7 and provide overnight treatment/stays.
2.
Function of a Flu Centre
A Flu Centre is a site that is either not currently an established health care service or is an established health care site that usually offers a different type or level of care. Flu Centres will: • provide a consistent approach to assessing patients with influenza-like symptoms
• triage and refer patients to the appropriate type and level of care
• provide access to self-care information and treatment for patients who are not ill enough to require hospital care
• distribute antivirals. These guidelines were developed to help local planners develop Flu Centres to provide the following basic functions: • assess individuals for influenza
• administer antiviral drugs and other therapeutics for treatment in accordance with clinical guidelines provided at the time of the pandemic
• provide supportive care strategies to ease symptoms
• educate patients about possible complications.
• refer individuals to the appropriate community-based agency or hospital for follow-up and care if required. Communities that choose to provide more advanced patient care, such as overnight treatment/stays or advanced assessment/ treatment procedures, will have to consider the more robust skill sets that will be required.
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3.
Organization, Structure and Funding of Flu Centres
Flu Centres will be temporary additions to the health care delivery system, and will be planned and managed locally. Advisory Committee Communities are encouraged to establish an Influenza Assessment Committee to oversee primary care services as well as the development of their Flu Centres. Membership should include: communitybased health care providers, hospitals, public health, municipal emergency management services, municipal public works, policing services, and the volunteer sector. Lead Agencies Because communities are in the best position to determine how to meet their planning needs, the lead agency designated to oversee planning for the implementation of Flu Centres shall be identified locally. For those communities that are unable to identify a lead agency to coordinate planning, the MOHLTC will designate one. The Advisory Committee will support the lead agency in planning to implement each Flu Centre. Together, the lead agency and Advisory Committee will identify which groups/organizations in the community is best positioned to manage Flu Centres once they are opened. Eligibility for Flu Centre Services and Documentation
Assessment Record (see Chapter 11A: Influenza Assessment, Treatment and Referral Centre Tools) for the initial assessment and treatment. The Primary Assessment Record will accompany the patient through the Flu Centre and to other treatment sites if required. For patients who have to be admitted to hospital, the hospitals will use the Primary Assessment Record (see Chapter 11A: Influenza Assessment, Treatment and Referral Centre Tools) as well as the Secondary Assessment for Hospital and the Influenza Admission form (see Chapter 17: Acute Care Services). These forms can be downloaded from the Ministry of Health and Long-Term Care website at: www.health.gov.on.ca/pandemic. Patient Flow Figure 11A.1 illustrates the route that patients will take to access a Flu Centre, as well as patient flow through the centre and options for treatment and referral. Funding Funding for Flu Centres will be provided by the MOHLTC, which will cover all expenses, including costs associated with procuring equipment and supplies. Surveillance and Epidemiology The Flu Centres will be an important source of information about the progress of the pandemic. The ministry will develop systems to collect information on flu centre visits.
To encourage the public to use the Flu Centres, the centres will not require people to have a Health Card for assessment and treatment. These services will be available at no cost to the patients. The Flu Centres will use unique identifiers to track patients. To streamline the assessment and treatment process, all settings will use the Primary
Chapter #11A: Influenza Assessment, Treatment and Referral Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 11A.1: Patient Flow to and through Community-Based Flu Centres
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4
Developing Flu Centres
• military facilities/armouries
Administrative Options
• churches
A Flu Centre may be a satellite of an existing health care facility or a free-standing site. A satellite is preferable because administrative and clinical structures are already in place including: • systems for ordering, tracking, and maintaining equipment and supplies
• surgical centres/medical clinics
• record keeping and patient tracking systems
• nursing protocols and patient care guidelines
• access to expertise and human resources • access to services such as laboratory, pharmacy, laundry, and food services
• security • referral networks • liability, workers compensation, and other insurance programs. Free-standing Flu Centres would have to address all of the above and develop partnerships with acute care hospitals to support patient referrals and transfers. Site Selection During the interpandemic period, the local planning group should conduct regular community-wide space and site assessments, and maintain a list of preferred sites for Flu Centres. The list should include back-up sites in case the preferred sites are not available or more capacity is required during the pandemic. Possible locations include:
• schools
• community/recreation centres • sports facilities/stadiums • convalescent care facilities • trailers • fairgrounds • tents • government buildings • warehouses. Criteria for Site Selection
When selecting a site for a Flu Centre, consider the following: Infrastructure
• Are doors/corridors wide enough to accommodate gurneys?
• Is the site wheelchair accessible? • Is there a loading dock? • Is there adequate free parking for staff and visitors?
• Are there enough toilet facilities? • Is the building structurally sound? Total Space and Layout
• Are there large rooms on the ground floor?
• Are there areas for registration, triage, treatment, pharmacy, ambulatory and non-ambulatory services?
• Is there space to set up accessible hand hygiene stations in multiple locations around the site?
• hotels/motels
• Are there family areas?
• convention centres
• Is there space that can be used for
• meeting halls • aircraft hangars
serving refreshments or food for staff?
• Are there areas for equipment storage?
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• Is there adequate administrative space (i.e., staff rooms; space for team debriefings, staff updates, and training sessions; links with public health; space for communication functions)?
• Will the space accommodate a single public entrance as well as separate exits for patients being discharged to the community and for patients being transported to hospital? Utilities
• Is the space gas heated? (preferred) • Is the site equipped with a power generator?
• Is there adequate ventilation and air conditioning?
• Is there adequate lighting? • Is it possible to make laundry arrangements? Communication
• Is the site wired for information technology/Internet access?
• Are there enough phones with long distance capability?
• Is there an intercom system? • Is there the capacity to use two-way radio systems? Other Requirements
• Is it possible to lock down the site? • Is the site publicly owned? (preferred)
• Is the site located in a well-known, accessible area? (e.g., major roadway)
• Is it close to a hospital emergency department?
• Can oxygen be delivered to the site? • Can arrangements be made for biohazard and other waste disposal?
• Is building security adequate? • Does it meet National Building Code standards? Table 11A.1 is a selection matrix tool that can be used to grade and compare a number of potential sites. Evaluation factors can be modified based on the potential timing of the pandemic (i.e., summer versus winter) and needs of the community. The weights are based on a 0 to 5 rating scale (bad to good). When sites are selected, the Advisory Committee should negotiate agreements to use the facility in advance of a pandemic. Site Insurance The Advisory Committee/lead agency must make arrangements for appropriate insurance coverage to use the site to provide health care services. Coverage should include fire, damage, theft, and site liability insurance. If the Flu Centre is a satellite site, investigate extending the sponsoring organization’s existing insurance program to cover the satellite site.
• How quickly can the site be converted into a care centre?
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Factors: Infrastructure Doors/corridors adequate size for gurneys Floors Loading dock Parking for staff and visitors Roof Toilet facilities (#) Ventilation Walls Total Space and Layout Auxiliary spaces (Rx, counsellors, chapel) Equipment/supply storage area Family area Food supply and prep area Mortuary holding area Pharmacy area Staff areas Utilities Air conditioning Power supply (backup?) Heating Lighting Refrigeration Water (hot?) Communication Communication (# phones, local/long distance, intercom) Two-way radio capability to main hospital
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Others
Trailers/Tents (Military, etc.)
Sports Facilities/Stadiums
Schools
Surgical Centers/Clinics
Military Facilities
Meeting Halls
Hotels/Motels
Government Buildings
Fairgrounds
Convention Facilities
Convalescent Care Facilities
Community /Rec. Centres
Churches
Aircraft Hangars
Potential Sites:
Table 11A.1 Assessment and Treatment Centre Selection Matrix
Wired for IT and internet access Other Services Ability to lock down facility Accessibility/proximity to public transportation Biohazard and other waste disposal Laundry Ownership/other uses during disaster Oxygen delivery capability Proximity to main hospital TOTAL RATING/RANKING (Largest number indicates best site)
Rating System 5
Equal to or same as hospital.
4
Similar to that of a hospital, but has SOME limitations (i.e., quantity/condition).
3
Similar to that of a hospital, but has some MAJOR limitations (i.e., quantity/condition).
2
Not similar to that of a hospital, would take modifications to provide.
1
Not similar to that of a hospital, would take MAJOR modifications to provide.
0
Does not exist in this facility or is not applicable to this event.
Source: Denver Health and the Rocky Mountain Regional Model for Bioterrorist Events Working Group
Equipment and Supplies At the time of a pandemic, the province will fund all Flu Centre expenses, including costs associated with procuring equipment and
supplies. The province will take responsibility for direct procurement of SOME equipment and supplies for Flu Centres (see below); local Advisory Committees/lead agencies will be
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Others
Trailers/Tents (Military, etc.)
Sports Facilities/Stadiums
Schools
Surgical Centers/Clinics
Military Facilities
Meeting Halls
Hotels/Motels
Government Buildings
Fairgrounds
Convention Facilities
Convalescent Care Facilities
Community /Rec. Centres
Churches
Aircraft Hangars
Potential Sites:
Ontario Health Plan for an Influenza Pandemic August 2008
Ontario Health Plan for an Influenza Pandemic August 2008
responsible for procuring other supplies. Local planners will be reimbursed for their expenses at the time of a pandemic. See Table 11A-2 for the equipment and supplies required for Flu, as well as whether the supplies will be procured provincially or locally. [Note: Supplies marked with * may not be required, depending on local decisions on the extent of services to be provided at the flu centre.] During the interpandemic period, the Advisory Committee/lead agency should identify sources for the equipment and supplies they are responsible for procuring and discuss with suppliers their ability to meet anticipated needs at the time of a pandemic. The National Emergency Stockpile System (NESS) was developed primarily for use in crises where there is a sudden need for supplies and equipment to deal with a large number of people with varying medical needs. The components of the kits are packaged and stored in warehouses across Canada to facilitate timely distribution. In the event of a local emergency that overwhelms municipal resources, municipalities may contact provincial emergency management authorities to access the supplies. Potential access to NESS supplies should be considered during planning. However, as a pandemic will likely occur simultaneously in a number of communities across the province, the NESS will not be able to meet all needs, and communities should have other supply sources.
For Flu Centre Staff:
PPE (N95 respirators, gowns, eye protection) = # staff/shift X 4 PPE changes/shift1 X 3 shifts/day X 56 days X # Flu Centres Gloves = # staff/shift X # patient interactions/staff X 3 shifts/day X 56 days X # Flu Centres For patients and caretakers:
Surgical masks = [1 mask/patient X # patients (based on OHPIP projections for outpatient visits)] X 2 For more information on the assumptions underlying these formulae, see section 6 of these guidelines. These formulae will be used by the province during the interpandemic period to establish PPE stockpiles.
Planning Formula The following formulae have been developed to help the province calculate the quantities of personal protective equipment (PPE) required to deliver patient care at Flu Centres:
1
Flu Centre staff should change PPE according to routine practices.
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Table 11A.2: Procurement Responsibilities Provincial responsibility
Local responsibility
Hand Hygiene
Cleaning Supplies
• • • •
Liquid soap Alcohol hand rub Paper towels Dispensers for soap and alcohol hand rub
Personal Protective Equipment • • • • •
Surgical/procedure masks (adult and child) N95 respirators Paper gowns Non-latex exam gloves Eye protection
• • • • • • •
Garbage bags Garbage cans One-use paper towels Specialized disposal bags for vomit/diarrhoea Laundry soap and/or laundry bags Mops Buckets
Paper Products • Paper square absorbent examination table cover • Paper cups
Vital Signs Assessment • Thermometers (disposable thermometers or disposable covers) • Stethoscopes • Blood pressure cuffs (adult and child) • Oxymeter and probes • Tongue depressors • Flashlights (medical)
Other medical supplies • First aid kit • Body bag/gurney • *Cots/mats • Blankets (disposable) • CPR valve • Bag valve mask resuscitator • Automatic External Defibrillator • Assessment forms • Adverse reaction forms • Self-care/education materials (multi-language) • Facial tissues • Wheel chairs • Exam tables
Disinfectants • Disinfecting wipes • Surface cleaner and disinfectant
Administrative Supplies • Ticket number machine • Clipboards • Flip charts and paper • Envelopes • File boxes • Colour-coded identification badges/vests for staff • Paper • Note pads • Pens, pencils, markers • Post-it notes • Signage • Stapler and staples • Scissors • Elastic bands • Tape • Flashlights • Portable partitions (or other material to provide private assessment areas) • Rope for cordoning areas • Saw horses/rope cordoning stands/traffic cones • Collapsible chairs • Portable toilets • Toilet paper • Colouring materials for children (e.g., colouring books, crayons) • Fire extinguishers • DVDs (children's movies/television programs)
Antiviral Clinic Supplies • Medication information sheets • Paper bags (small)
I&IT Supplies • Telephones (fixed and mobile) • *Teleconferencing equipment
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• • • • • • • •
Computers Printers and toner Public announcement system/bullhorns 2-way hand-held radios/messaging devices for key personnel and security staff DVD/TV (for orientation/ training and waiting room) Fax machine Photocopier/scanner Computer paper
Pharmaceuticals • • • •
5.
Antivirals Antibiotics Anti-diarrhoeal medication Anti-nauseant medication
Criteria for Opening a Flu Centre
Communities should establish criteria for when their Flu Centres will become operational. The decision to open Flu Centres will be based on the severity of the pandemic and its impact on existing health care services. Possible criteria include: • reports from local primary care providers that they can no longer assess and treat people with antivirals within 12 to 24 hours of the onset of symptoms
• confirmation of a severe pandemic in a neighbouring area
• proportion of emergency room visits attributable to influenza
• proportion of influenza cases requiring hospitalization.
6.
Site Management
Command Structure The Advisory Committee/lead agency will develop a command and control structure for the Flu Centre that can be integrated with the existing local emergency command structure. A copy of the organizational chart should be given to all staff and posted in the Centre. Figure 11A.2 illustrates a command structure based on the Incident Management System (IMS), an international emergency management structure that has
been adopted by the Government of Ontario. The IMS consists of five components (command, operations, planning, logistics, and finance and administration) and three support elements that report directly to Command (safety, liaison, and communications). The structure is simple and can be applied to any organization involved in emergency management. It also makes communication and cooperation among organizations easier and the process of managing an emergency more efficient. For example, Flu Centre planning staff will be able to communicate directly with planning staff at other health care facilities or at the Municipal Emergency Operations Centre. The Ministry of Health and Long-Term Care is using the same organizational structure for the Ministry Emergency Operations Centre, which will help improve the effectiveness and interoperability of emergency management in the province. Advertising and Promoting the Flu Centres For the Flu Centres to be effective in diverting people away from their primary care provider or hospital emergency departments, the public must be aware that they exist and know how to access them. During a pandemic, public messages issued by the MOHLTC will direct people who are experiencing symptoms to call Telehealth
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where they will be directed, if necessary, to a Flu Centre. At the local level, the Advisory Committee should work with local health organizations and local media to ensure the public is aware of the locations of Flu Centres as well as when and how to use them.
7.
Staff Requirements
Staffing Staffing Flu Centres will be a challenge. The Advisory Committee will have to develop staffing strategies based on assumptions about current services including: the curtailing of some services during a pandemic which will free up staff, the willingness of staff in some community organizations to work in the Flu Centres, the liberal use of volunteers, and the tailoring of health care delivery to meet the demand in an influenza pandemic. The number of people who can be seen at a Flu Centre will depend on the number of staff, particularly those providing nursing care. Ontario is using a competency-based (rather than a credential-based) approach to health human resources planning and deployment during an influenza pandemic (see Chapter 8). This should allow for greater flexibility in assigning tasks and deploying staff. The competencies required at a Flu Centre include health care competencies (e.g.,
diagnosis, prescribing medications) as well as other competencies required to run the Centres. They fall into five broad categories:
• Administrative/support services: including site administration, health records management, and communications infrastructure.
• Transportation services: for patients. Transportation may also be needed for staff if public transit is reduced and/or to reach rural areas.
• Education: including education of health care workers, staff, and volunteers (including training for workers who may be extending their scope of practice); and public education on preventing influenza and self-care.
• Infection control/occupational health and safety/surveillance: including training in infection control and monitoring workplace safety, as well as providing psychosocial and logistic support.
• Care of ill persons: including assessing patient status, developing a care plan, providing direct care to patients who are ill with influenza, determining whether additional care is required and determining whether the patient can be discharged from the Flu Centre.
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Figure 11A.2: Influenza Assessment, Treatment and Referral Command Organization
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A Flu Centre staffing model (Table 11A.3) has been developed to summarize the functions of staff required to operate a Flu Centre. This model can be modified to meet the specific needs of individual communities by scaling staffing levels to the population level the Flu Centre will service. Note: One staff person may perform one or more of the functions listed in Table 11A.3 – depending on the size of the community and the number of people the Flu Centre will serve. The staffing model aligns with IMS, as well as the competency-based approach described in Chapter 8. The province will use the staffing model to estimate equipment and supply needs (particularly for personal protective equipment) and is based on the following assumptions: Flu Centres will be established in all jurisdictions
12:30; shift 2 is from 12:00-19:00; and shift 3 is from 18:30-00:30)
the staffing model aims to minimize the number of staff directly in contact with clients, thereby reducing their risk of exposure to influenza. Where possible, staff will work remotely from other locations or in rooms that are separate from patient/client areas
staff will change personal protective equipment (PPE) according to routine practices
all staff on-site will have access to a full complement of PPE (i.e., N95 respirator, gloves, gown, eye protection)
each patient at the Flu Centre has influenza; therefore, the goal is to protect staff from contracting influenza and not to protect the patients from each other
Flu Centres will assess 900 patients per day over an 18-hour time period
each patient may be accompanied by one caretaker (e.g., parent, spouse)
assessment staff will spend 15 minutes/patient
surgical masks will be worn by patients and caretaker.
hours of operation are 6:00-24:00 with three shift changes (shift 1 is from 5:30-
Table 11A.3: Flu Centre Staffing Model Function
Skill Sets
Quantity
Location
Management /Administration, familiarity with Incident Management Structure
1
On-site
Occupational health and safety background, familiarity with infection control and prevention
1
On-site
Communication/language skills, public relations, medical management skills, or if unavailable, refer to site administrator
1
Off-site
Command Site Administration/ Management Safety On-site safety officer Communications Spokesperson - to communicate with media, etc. Liaison
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Function
Skill Sets
Quantity
Location
Communication liaison between municipal and/or public health unit Emergency Operations Centre (EOC) and Flu Centre
Communication/language skills, public relations, problem solving skills
1
Off-site in the EOC
Scheduling/human resources knowledge, leadership and coordination skills
1
On-site
Physician or nurse/nurse practitioner with physician backup
1
On-site
Knowledge of basic patient care, patient triage, infection control, occupational health and safety
1
On-site
Planning Labour Pool Co-ordination of Patient Care - staff scheduling and support, assessing service demands and supply Admissions/Discharge Medical Management Training On-site training and orientation of staff, volunteers, and family members Operations Reception/Registration Zone – Register incoming patients, Initiate Primary Assessment Record (PAR), Security Receptionist
Communication/language skills, public relations, translation, basic infection control knowledge, clerical skills (including computer skills), confidentiality agreement
3
On-site
Data entry clerks
Clerical and records management skills (including computer skills), confidentiality agreement, basic infection control knowledge
1
On-site
Information technology resource
Knowledge of IT systems, problem solving skills, basic infection control knowledge
1
On-site
Greeters
Communication/language skills, problem solving skills, basic infection control knowledge
2
On-site
Public order and personal safety
Crowd control, traffic control, minimize family in attendance
2
On-site
Medical triage
Medical training/nurse, ideally with ER training
1
On-site
Waiting Zone – Assist patients in completing PAR and medication list, Distribute education materials Waiting Zone Monitors
Ability to monitor people, people skills, basic infection control knowledge, ability to assist individuals in completing the PAR
2
On-site
Assessment Zone – Take vital signs, Assess chest, Complete PAR sections 2, 4, 5, 6 Patient assessment – medical/nursing
Patient assessment skills: re-hydration, ambulation, vital signs monitoring, ability to administer medication
13
On-site
Medical triage/patient flow management
Medical training/nurse, ideally with ER training
2
On-site
Public order and personal safety
Crowd control, traffic control, minimize family in attendance
2
On-site
Education/Discharge Zone – Provide discharge instructions and education resources, Liaise with transfer agency, Provide assessment documents, Implement PAR Section 5 and follow-up, Security Discharge planner
Knowledge of resources available to assist patient at home
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6
On-site
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Function
Skill Sets
Quantity
Location
Discharge registration clerk
Clerical skills (including computer skills), confidentiality agreement, basic infection control knowledge
4
On-site
Public order and personal safety
Crowd control, traffic control, minimize family in attendance
2
On-site
Patient care skills: re-hydration, feeding, ambulation, vital signs monitoring, ability to administer medication
1
On-site
Dispensary support staff
Pharmacist/pharmacist assistant
2
On-site
Public order and personal safety
Crowd control, traffic control, minimize family in attendance
1
On-site
Local businesses or building owner
1
On-site
Procurement background, preferably in medical-related field
1
Off-site
Basic knowledge of infection control, biohazardous waste disposal, Workplace Hazardous Materials Information System (WHMIS)
6
On-site
Background in procurement/transportation
1
Off-site
Procure drinks/refreshments for patients
Local businesses, basic food safety training
1
Off-site
Food preparation - workers' meals
Local businesses, basic food safety training
1
Off-site
Knowledge of financial and accounting systems, computer skills
1
Off-site
Knowledge of financial and accounting systems, computer skills
1
Off-site
Advanced First Aid and Transfer Zone – Serve patients who arrive in distress, PAR 4, 5, 6 Patient Care – advanced care paramedic/medical/nursing Pharmacy Zone
Logistics Maintenance Maintenance of facility, etc. Materials/Supply Unit Procure supplies and equipment for Flu Centre Housekeeping Unit Housekeeping/environmental services Resource Transportation Unit Transportation of supplies and equipment Food Service Unit
Finance and Administration Cost Accounting Unit Accountant Procurement Financial administrator
Staff Recruitment As part of local pandemic planning, communities should establish a registry of health care providers, non-medical staff, and
volunteers who could be available to staff a Flu Centre. Potential sources of staff include:
• active primary care providers (e.g., physicians, nurse practitioners)
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• public health departments
• provision of clothing and equipment
• temporary nursing agencies
• protection of the jobs of workers who
• laboratories • allied health professionals (e.g., pharmacists, therapists, dieticians)
• private ambulance companies • allied and home health agencies • retired health care professionals • health professionals not working in health care or otherwise inactive
• fire/emergency/police departments • the Canadian military • education institutions (e.g., nursing, medical, or veterinary students)
• veterinarians • volunteer agencies. (e.g., faith groups, Canadian Red Cross, volunteer fire departments, St. John Ambulance, Scouts, Guides). Volunteers may play a key role in performing functions that do not require particular health care competencies (see Chapter 8: Optimal Deployment of the Health Workforce). Emergency legislation makes provisions for the management of workers, both paid and unpaid, during a crisis. Local planners should familiarize themselves with existing legislation, especially laws related to the following topics:
• authority regarding licensing and scope of practice issues
• safety and protection of workers • fair compensation • insurance, both site insurance, workers’ compensation, and other forms of insurance
• training
take leave to assist during the pandemic. The Advisory Committee/lead agency should also investigate compensation rates for all paid staff working at the Flu Centre. Payments should be based on current arrangements and labour agreements. Training Staff will require training to prepare them for their roles at a Flu Centre. Health care workers and volunteers may require training in skills such as infection control, emergency management skills/IMS, the use of personal protective equipment, self-care guidelines, stress management techniques, and the use of respirators. As much as possible, training should be provided during the interpandemic period. For health care workers, pandemic-related training can be incorporated into existing training programs, while volunteer agencies should be encouraged and supported to start training volunteers. Potential training curricula include:
• on-line courses • St. John Ambulance Brigade. Brigade Training System. 1997
• St. John Ambulance Brigade. Handbook on the Administration of Oxygen. 1993. ISBN 0-919434-77-0
• The Canadian Red Cross Society. Yes, You Can Prevent Disease Transmission. 1998
• nursing colleges training programs (i.e., basic care programs for health care aides)
• CHICA, APIC, and the Infection Control Association in the UK have a “tool kit” with detailed forms and templates, 2002. [Reference: “Infection Control Toolkit” Strategies for Pandemics and Disasters, can be ordered through the Community
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and Hospital Infection Control Association (CHICA - Canada), Phone: 204-897-5990 or toll free 866-999-7111; Email:
[email protected]]. Support Health care workers, patients, family members, and the general public may experience acute stress during the pandemic. Mental health services must be available on-site to help people with their mental health needs. Protocols must also be in place to assist patients with non-medical needs, like housing, employment, food, and spiritual guidance. Social workers, religious leaders, community officials, and volunteer agencies can all be engaged in these activities.
8.
Infection Prevention and Control Measures
Each Flu Centre must establish occupational health and safety, and infection prevention and control policies and procedures to minimize transmission and protect staff, patients, and visitors. According to the command structure outlined earlier, Flu Centres may need either Joint Health and Safety Committee or Representative (depending on the number of employees) and should have a designated safety section responsible for infection prevention and control measures at the site, including:
• providing education • ensuring hand hygiene supplies (e.g., alcohol-based hand rub, tissues) are readily available
• posting signs about routine infection prevention and control measures (e.g., hand hygiene, cough etiquette)
• providing guidance on personal protective practices and equipment
• establishing and maintaining cleaning procedures and a regular cleaning schedule for workspace and equipment that will support the operation of the Flu Centre
• working with other health care workers in the community to implement and reinforce an awareness campaign about routine infection prevention and control practices that can prevent the spread of respiratory illness. For information on recommended occupational health and safety and infection prevention and control measures – including environmental cleaning – see Chapter 7.
9.
Clinical Management
Patient Triage Providing assessment and triage services at Flu Centres will not only reduce the pressure on hospital emergency departments, family physicians, and walk-in clinics, it may reduce public exposure by keeping influenza-like illness contained in a small number of sites in the community. The MOHLTC has developed a Primary Assessment Record that Flu Centres will use to assess patients face-to-face and direct them to the right level of care. With this system, Flu Centres will direct patients who need a higher level of care to acute care hospitals. The MOHLTC is currently developing a standard screening tool that will be used by all health care settings to screen people by phone and determine whether they should be counseled about self-care, referred to a Flu Centre or referred to a hospital. Patient Tracking Flu Centres that are satellites of an existing health care facility will use the facility’s patient tracking system. Stand-alone Flu
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Centres must develop patient tracking protocols. All patients must be tracked through the process. Information to be obtained includes:
• a patient identification number • name • date of birth • address • phone number • emergency point of contact • medical history. Flu Centres will also be responsible for participating in surveillance activities, as directed by the local public health unit (e.g., adverse events related to antivirals and vaccines, number of outpatient visits, number of deaths). See Chapter 5 for more information on surveillance activities during the pandemic period. Transportation Flu Centres must have transportation protocols for transferring patients and personnel. See appendices for a sample protocol for transferring patients from a Flu Centre to an acute care facility. Issues to consider include: transportation between hospital facilities and the Flu Centre, recording of all arrivals and departures to and from the Centre, coordinating transportation to patients' homes, and overseeing ambulance services. All patient transfers to other health care settings (e.g., hospital, long-term care facility) will need to be arranged through the Provincial Transfer Authorization Centre. Because EMS may be operating at full capacity, Flu Centres may have to use non-traditional forms of transportation (e.g., volunteer drivers). Provisions for Children Children have special needs, both physically and psychologically, that Flu Centres must take into account in the way they organize
space and deploy staff (see Chapter 18: Paediatric Services). For example, Flu Centres should:
• cohort children in the same treatment subunit
• minimize separation from parents and involve family members in the child’s care as much as possible
• ensure health care workers who have childcare experience are available
• procure paediatric equipment and supplies.
10. Security and Traffic Control Flu Centres will require security – particularly if they are distributing antivirals – to assist with patient flow through the Flu Centre. Flu Centres should also develop traffic control procedures, including controlling the entrance and exits, directing traffic around the site, maintaining controlled points of entry for staff and patients, establishing secure sites for staff and patient parking, and securing ambulance staging and supply delivery zones.
11. Overnight Service and Stays Most Flu Centres will operate extended daytime hours – 18 hours a day – to meet the population’s health needs. However, based on the community’s needs, some Flu Centres may have to operate 24 hours a day, 7 days a week, and will have to take additional steps to plan and provide services. Function of an Overnight Assessment and Treatment Centre Flu Centres established to provide overnight care could play the following roles:
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• act as a temporary influenza hospital for the care of patients who are not critically ill but not well enough to return home
• provide housing/care for influenza patients who live alone or who live with someone at high risk of complications from influenza
• act as “step down" units and provide care for stable patients who have been transferred from acute care hospitals but are not well enough to go home. The level of care provided at an overnight Flu Centre should be limited to supportive or palliative care. Critical care should remain the domain of an acute care facility. Site Selection When choosing a site for an overnight Flu Centre, the Advisory Committee/lead agency should consider the following (in addition to the earlier criteria for site selection):
• Does the site have large areas suitable for setting up (multiple) treatment units and enough space to allow treatment beds to be located at least one metre apart?
• Does the site have adequate showering and bathing facilities?
• Is the site close to a hospital? Planners should modify the selection matrix in Table 11A.1 to reflect the specific needs of their community. Equipment and Supplies The services and level of care the Flu Centre offers will dictate equipment and supply needs. See Chapter 10 for more information on equipment and supply requirements. Staff Requirements The Advisory Committee/lead agency will have to determine the human resources required to operate a Flu Centre 24 hours a day/7 days a week over the period of a pandemic wave (i.e., about 8 weeks). To do this, the Advisory Committee should identify the level of care to be provided, the competencies required to deliver that care, job descriptions and the number of staff and volunteers required. (See 6. Staff Requirements in this chapter, and Chapter 8: Optimal Deployment of the Health Workforce.)
• Does the site have space to accommodate enhanced food preparation/service facilities to provide meals for patients?
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Triage Zone Matrix Equipment
Service Zone
Patient Assessment Record (PAR)
Required Skill Set Required
Source
(In addition to protective wear for staff)
NGO
computer stations
Registration Zone
Register in-coming patients Initiation of Primary Assessment Record (PAR): Personal Information Security
computer literate
Waiting Zone
Awaiting Primary Assessment PAR History (patient with help from volunteer) Medication List
people skills
people skills work under pressure translators ability to maintain order ability to use PPE English language skills
automated translation centres
NGO
work under pressure ability to monitor patients
easy-to-clean chairs
Tools to be Developed
Patients not Suitable for Assessment
Registration document* Training for volunteer**
Training for volunteer** Assessment forms* Medication List
(patient with help from volunteer) Distribution of educational materials Assessment Zone
Vital signs PAR Assessment Section 4 Chest auscultation and assessment PAR Assessment Section 2, Orders Section 6 and Discharge Section 5
able to take temperature, blood pressure, pulse, respirations able to interpret chest sounds and complete assessment translators make diagnoses
NGO Health professional: NP/RN/RT from community Local community volunteers
electronic or disposable thermometers BP cuffs and stethoscopes
Training for volunteer** Assessment Forms*
stabilized for transfer to other setting
prescribe meds ability to recommend treatment plan Advanced First Aid & Transfer Zone
Service to patients who arrive in distress (or are directed to zone) including oxygen, suction, etc. while they await transfer to emergency department PAR Assessment Section 4, Orders Section 6 and Discharge Section 5
advanced first aid judgment
Education Zone
Discharge instructions Educational resources
identify appropriate discharge material/information training / teaching skills translators
PAR Section 5
CPR equipment
stabilized for transfer to other setting
ability to deal with distressed people advanced care paramedic/ physician/nurse practitioner from community ability to recommend treatment plan prescribe antivirals NGO local community volunteers
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Development of discharge information in multiple languages* Training for volunteer**
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Equipment
Service Zone
Patient Assessment Record (PAR)
Discharge Zone
Liaison with transfer agency: provision of assessment document(s) PAR Section 5 Follow-up as per PAR Security
Required Skill Set Required
Source
organization skills
NGO
(In addition to protective wear for staff)
telephone skills office skills ability to assess activities of daily living (ADL) capacity & home support ability to dispense antiviral medications
Tools to be Developed
Patients not Suitable for Assessment
Transfer protocol* Training for volunteer**
* Provincial Responsibility ** Local Responsibility
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Transfer Protocol from Flu Centre to an Acute Care Facility The movement and transfer of patients with influenza should be limited as much as possible; however, influenza patients with severe complications who arrive at Flu Centre must be transported to an acute care facility – which may be in a separate institution, a separate part of the same institution, or within the same building. When transporting patients from a Flu Centre to an Acute Care facility, the following transfer protocol should be followed:
2. Precautions will be taken in
A. Flu Centre and Hospital are Located in Separate Institutions
attached to patient and required for
1. The facilitating nurse or designate will
preparation for transport:
• Patients must wear a surgical mask during transport.
• Trolley/wheelchair must be lined with disposable sheet.
• Transport and facility staff must wear full personal protective apparel (i.e., hair cover, single gown, gloves, protective eye wear, N95 respirator). 3. All medications/equipment not directly patient care must be transported in a biohazard bag.
coordinate the transport by calling:
4. Patients will follow a specific transfer
• the receiving department or unit to
route.
ensure the patient’s/procedure room is ready and staff will be ready to receive the patient on arrival
• the Provincial Transfer Authorization Centre (PTAC) to obtain an infectious disease referral medical transfer (MT) authorization for the inter-facility movement of the patient by ambulance or private medical transportation service
• the ambulance or private medical transportation service provider, advising him in advance about the personal protective equipment requirements and precautions to be taken
• Administration/management will establish dedicated entry and internal pathways for transferring severely ill patients (e.g., dedicated elevators, corridors, entrances, exits).
• Patients will be escorted out of the Flu Centre by paramedics. If a medical transportation service is utilized, the patient will be escorted out of the Flu Centre by both medical personnel and medical transport staff.
• Upon arrival at the hospital, the designated route for the transport of influenza patients will be followed.
• respiratory therapist(s) if the patient has
5. Only those staff members required for
O2 saturation level less that 95% or is on oxygen
the transport (i.e., paramedics or medical
• security to ensure designated routes for transport of influenza patients are followed (these routes must be separate from main traffic route/s).
personnel/attendant staff) will be allowed to accompany the patient along the predesignated alternate transportation route/s. 6. Site administrators or designate will document the following:
• date of transport
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• time of transport • patient name • location of where transport was initiated and ended
• names of health care workers involved (e.g., porter, nurse)
• signature of security personnel documenting transport.
• Trolley/wheelchair must be lined with disposable sheet.
• Transport and facility staff must wear full personal protective apparel (i.e., hair cover, single gown, gloves, protective eye wear, N95 respirator). 3. All medications/equipment not directly attached to patient and required for patient care must be transported in a
7. Environmental services must ensure
biohazard bag.
effective cleaning of all contaminated
4. Patients will follow a specific transfer
surfaces.
route.
• Wipe surfaces of the trolley/wheelchair
• Administration/management will
with disinfectant after use.
• Wipe any other surfaces that came into contact with the influenza patient. B. Flu Centre and Hospital are in Separate Parts of the Same Institution 1. The facilitating nurse or designate will coordinate the transport by calling:
• the receiving department or unit to ensure the patient’s/procedure room is ready and staff are ready to receive the patient
• the ambulance or private medical transportation service provider, advising him in advance about the personal protective equipment requirements and precautions to be taken
• respiratory therapist(s) if the patient has O2 saturation level less that 95% or is on oxygen
• security to ensure designated route/s for transport of influenza patients are followed (these routes must be separate from main traffic route/s).
establish dedicated entry and internal pathways for transferring severely ill patients (e.g., dedicated elevators, corridors, entrances, exits).
• Patients will be escorted out of the Flu Centre by paramedics. If a medical transportation service is utilized, the patient will be escorted out of the Flu Centre by both medical personnel and medical transport staff.
• Upon arrival at the hospital, the designated route for the transport of influenza patients will be followed. 5. Only those staff members required for the transport (i.e., paramedics or medical personnel/attendant staff) will be allowed to accompany the patient along the predesignated alternate transportation route/s. 6. Site administrators or designate will document the following:
• date of transport • time of transport
2. Precautions will be taken in
• patient name
preparation for transport:
• location of where transport was initiated
• Patients must wear a surgical mask during transport.
and ended
• names of health care workers involved (e.g., porter, nurse)
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• signature of security personnel documenting transport. 7. Environmental services must ensure effective cleaning of all contaminated
3. All medications/equipment not directly attached to patient and required for patient care must be transported in a biohazard bag.
surfaces.
4. Patients will follow a specific transfer
• Wipe surfaces of the trolley/wheelchair
route.
with disinfectant after use.
• Wipe any other surfaces that came into contact with the influenza patient. C. A Flu Centre is Located within the Hospital 1. The facilitating nurse or designate will coordinate the transport by calling:
• the receiving department or unit to ensure the patient’s/procedure room is ready and staff are ready to receive the patient
• porter(s) to notify them that an influenza patient requires transport with proper personal protective equipment
• respiratory therapist(s) if the patient has O2 saturation level less that 95% or is on oxygen
• security to ensure designated routes for transport of influenza patients are followed (these routes must be separate from main traffic route/s). 2. Precautions will be taken in preparation for transport:
• Patients must wear a surgical mask during transport.
• Trolley/wheelchair must be lined with disposable sheet.
• Transport and facility staff must wear full personal protective apparel (i.e., hair cover, single gown, gloves, protective eye wear, N95 respirator).
• Administration/management will establish dedicated internal pathways for transferring severely ill patients to be (e.g., dedicated elevators, corridors, entrances, exits).
• Patients will be escorted out of the Flu Centre by the porter/s.
• The patient will follow the designated route within the building. 5. Only those staff members required for the transport (i.e., porters) will be allowed to accompany the patient along the predesignated alternate transportation route(s). 6. Site administrators or designate to document the following:
• date of transport • time of transport • patient name • location of where transport was initiated and ended
• name(s) of health care workers involved (e.g. porter, nurse)
• signature of security personnel documenting transport. 7. Environmental services must ensure effective cleaning of all contaminated surfaces.
• Wipe surfaces of the trolley/wheelchair with disinfectant after use.
• Wipe any other surfaces that came into contact with the influenza patient.
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12. Communications There was terror afoot in 1918, real terror. … The media and public officials helped create that terror – not by exaggerating the disease but by minimizing it, by trying to reassure. … The fear, not the disease, threatened to break the society apart. … So the final lesson, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. … Those in authority must retain the public’s trust. The Great Influenza, John M. Barry
Effective internal and external communications provide the backbone for a coordinated response to an influenza pandemic. A wide range of groups at all levels will need to share accurate, timely and consistent information about what is known about the pandemic strain and the risks to public health, as well as advice on how to manage those risks at each stage of a pandemic.
12.1 Objectives During a pandemic, media attention will be intense, and information demands will continue over several months. Sustaining public and workplace confidence over that time will be a challenge. Credible spokespeople will be required nationally, provincially and locally to:
• •
educate Ontarians about the pandemic plan provide consistent, coordinated and effective public and provider communications
•
identify the communication activities that should occur during each phase of the pandemic
•
ensure health care workers have access to transparent, accessible, accurate, real time information that will help them respond to challenges during each phase of the pandemic
Chapter #12: Communications
•
ensure that health care workers can share lessons learned during each phase of the pandemic with planners who will use that information to continuously improve Ontario’s pandemic response.
12.2 A Comprehensive Approach to Pandemic Communications Ontario is committed to providing focused, timely, accurate, accessible and concise communications to/from/among four key audiences:
•
the public
•
health care workers
•
health care stakeholders (including health care employers, associations, regulatory colleges and unions)
•
internal audiences (i.e. MOHLTC staff, Ontario Public Service).
A comprehensive approach to communications reflects and supports the ethical framework for decision making during a pandemic (see Chapter 2), and its purpose is three-fold: To educate by:
•
encouraging Ontarians to take the threat of pandemic seriously
•
explaining how to prevent and treat influenza
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Ontario Health Plan for an Influenza Pandemic August 2008
•
providing information about influenza symptoms
•
describing the measures required to protect those at greater risk
•
conducting regular technical briefings for members of media
•
providing transparent, accessible, useful, accurate, technical, real time information for health care professionals that they can use to protect themselves and the public during each phase of the pandemic.
To reassure by:
•
demonstrating that government is prepared and has plans in place before a pandemic occurs
•
demonstrating that government has initiated its emergency response plan when required, is working with all other levels of governments and is taking all necessary steps to address the situation
•
issuing regular timely updates that provide accurate and relevant information
•
being responsive to information from the field/front lines and using that information to shape/adapt communication messages
•
recognizing the hard work and dedication of all health care workers
•
modeling a calm approach designed to reduce fear, avoid panic and encourage vigilance.
To be accountable by:
•
providing appropriate timely information
•
reporting regularly on the health care system’s ability to respond to the emergency.
Chapter #12: Communications
12.3 Communications during the Interpandemic and Pandemic Alert Periods There are many initiative tools either in place or being developed at the federal, provincial and local levels to communicate with the public and with health care workers and other stakeholders. With the public In the interpandemic and pandemic alert periods, the focus of public communications is on raising awareness of the risks of influenza and the steps people can take to prevent the spread of influenza, including influenza immunization. PHAC has launched a web-based portal to provide easy access to a wide range of pandemic information. The public can also access the weekly FluWatch bulletin as well as travel alerts and advisories about any countries experiencing outbreaks or unusual influenza activity. MOHLTC has developed a public information brochure titled: What you should know about a flu pandemic, which is available in 23 languages on the ministry’s website at: www.health.gov.on.ca/pandemic. During 2006, five million copies of the brochure were distributed to the public through various health care organizations and facilities. The ministry has also developed a series of fact sheets for the public, which are available in 23 languages on the ministry’s website. Every fall, the MOHLTC launches an extensive advertising campaign to educate the public about the benefits of annual influenza immunization and encourage all Ontarians to get their flu shot (i.e., the Universal Influenza Immunization Program). The ministry is also developing a direct public education campaign about the steps
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to take reduce the spread of all respiratory illnesses, including influenza (e.g., wash hands frequently, cover your cough/sneeze, stay home when ill). This education is designed to reinforce the importance of good hand and respiratory hygiene, and to encourage public cooperation and compliance with FRI screening and other precautions health care settings are now taking to reduce the spread of respiratory illnesses. At the local level, public health units actively promote immunization clinics, and provide information about how to prevent or reduce the spread of influenza. With health care workers, stakeholders and internal audiences (e.g., government) PHAC has established ongoing communication with key international organizations (e.g., WHO, PAHO) about influenza activity within and outside Canada, as well as mechanisms to facilitate pandemic planning with the provinces and territories. PHAC publishes the weekly FluWatch bulletin for public health and other health professionals, and has email or web postings for key stakeholders. The Ministry of Health and Long-Term Care has developed a number of communication mechanisms and tools, including:
•
updating its crisis communications plan
•
working with health care organizations and providers to develop a crisis communications toolkit for the health care sector (see Chapter 12A: Communications Tools)
•
updating existing stakeholder and provider fact sheets and developing new ones – these fact sheets are available on the ministry’s website in
Chapter #12: Communications
23 languages at: www.health.gov.on.ca/pandemic
•
developing iPHIS (integrated Public Health Information System) – a communications system to support the rapid timely exchange of surveillance information with both the federal government and public health units
•
distributing Important Health Notices, advising health care providers and other stakeholders of emerging and potential health emergencies.
At the local level, public health units:
•
work with health care settings to encourage education for providers about influenza, the risks and preventive practices
•
monitor immunization rates among health care workers in different settings, and provide information back to the health care settings, so they can compare their rates with those in similar settings
•
maintain pandemic contact lists that include local emergency services, fire, police, and health care facilities.
12.4 Communications during the Pandemic Period In the event of a pandemic, both PHAC and MOHLTC will activate their pandemic response plans. MOHLTC will use its Crisis Communications Plan to manage provincial health communications. During the pandemic period, communications will focus on providing upto-date accurate information about the pandemic to both the public and health care workers/stakeholders, informing them of the steps being taken to respond to the pandemic, and advising them what to do at each phase.
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With the public During a pandemic, PHAC will operate an around-the-clock public information line. MOHLTC will use a number of different mechanisms to communicate with the public during a pandemic, including Telehealth, Infoline, website, fact sheets, media briefings/press conferences, and advertising. Mechanisms are in place to ensure that Info line can double its capacity within 48 hours. With health care workers MOHLTC has developed an information cycle for use during a public health emergency, such as a pandemic (see Figure 12.1). Information will be issued and briefings held at the same time each day, ensuring that provider groups and the public/media receive regular timely reports. 0000 h
Important Health Notice goes out providing status update and any new directions so everyone has it for the start of the day.
0830 h
Teleconference with the Health Care Stakeholder Council (i.e., CMOH, EMU, regulatory colleges, professional associations, labour associations and organizations, and local health integration networks [LHINs]).
1000
Executive Emergency Management Committee (EEMC) meeting to provide update on new information from overnight and pressing issues.
1300
Public health teleconference with CMOH, PHD, LMOHs, and EMU.
1400
Teleconference with critical infrastructure sectors coordinated by the Provincial Emergency Operations Centre (PEOC).
1500
Media Conference.
1630
EEMC meeting to update on daily activities and issues.
Figure 12.1: MOHLTC Information Cycle in a Public Health Emergency
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During a pandemic, it is critical that frontline staff receive the information they need to work safely. In addition to Important Health Notices, MOHLTC will use a number of different mechanisms to communicate with health care workers and stakeholders (e.g., telephone, email, fax, website, videoconferencing, public education, advertising, stakeholder communications, and media relations). The MOHLTC will also activate the Health Care Stakeholder Council – a group made up of the CMOH, EMU and representatives from the professional associations, labour associations, regulatory colleges and regional offices – which is responsible for bringing forward issues, providing advice to the government, and ensuring effective communication with their constituencies.
Health care workers and health care stakeholders will be able to call the MOHLTC’s Emergency Management Unit Health Care Provider Hotline toll-free: 1-866212-2272 and/or visit the website at: http://www.health.gov.on.ca/english/ providers/program/emu/emu_mn.html
12.5 Communication Roles and Responsibilities During a health emergency, everyone has a role to play in maintaining a streamlined, effective communication system. Table 12.1 compares the roles and responsibilities for the ministry and the healthcare system in routine and emergency communications.
Table 12.1 Communication Roles and Responsibilities Organization
Role in Routine Communications
Ministry of Health and Long-Term Care
• • • • •
Website Publications Important Health Notices Call Centre 24/7 Earned media
Ministry of Labour
• • • • • • • •
Standards Inspections and enforcements Website notices Prevention Website Newsletter Standards and guidelines Earned media
Professional Association/ Organized Labour
• • • •
Website Newsletter Advocacy Earned media
Employer
• • • • •
Policies and procedures Training Intranet Employer 1-800 # Joint Health and Safety Committee
Regulatory College
Individual
• Awareness
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Role in Emergency Communications • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Daily Important Health Notices Information Cycle “Directives” Website updates Publications Call centres Teleconferences MEOC Media: earned & paid Targeted enforcement Website and media updates Prevention updates Government-wide communications Website Standards and guidelines Teleconferences Fan-out emails Earned media Website Teleconferences Fan-out emails Advocacy Earned media Modification to policies and procedures Review and revise measures for worker health and safety Training on revisions to usual practice Joint Health and Safety Committee Intranet “Town hall” meetings Awareness
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12.6 Next Steps
•
continue to monitor communications materials being used in other jurisdictions
•
assess the impact of its communications strategies on public awareness and the readiness of the health care sector
•
revise communication materials and strategies based on evaluation results.
Ontario will:
• •
continue to refine its pandemic communications plan develop and distribute communications materials to health care providers and the public
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12A. Communications Tools 1. Health Sector Crisis Communications Toolkit ...............................................................................1 Introduction 1. Trigger: When to Start Using this Toolkit ----------------------------------------------------- 1 2. Crisis Communications Team Roles and Responsibilities -------------------------------- 2 3. Step by Step: Communications in a Pandemic ----------------------------------------------- 4 Situation Scan Scenario Planning Grid New Information Report Key Audience Grid Communications Log Incoming Media Call Log Stakeholder Communications Checklist Internal Contact List 2. Communication Activities by Pandemic Period and Phase .......................................................18 3. Sample Important Health Notice.....................................................................................................21
Ontario Health Plan for an Influenza Pandemic August 2008
Health Sector Crisis Communications Toolkit This crisis communications toolkit was developed by health care stakeholders for the health sector in Ontario to facilitate communications during a pandemic. In the event of a pandemic, it is essential that communications among and between health care organizations, the Ministry of Health and Long-Term Care and the public be streamlined and coordinated.
Objectives The toolkit is designed to:
•
foster effective, two-way communications from organizations to and from MOHLTC
•
outline the communications tools the ministry will use to reach stakeholders, when those tools will be implemented, and how they will be distributed
•
provide a template crisis communications plan for stakeholders, and a guideline for communicating during a pandemic
•
be incorporated by organizations into their existing crisis plans using an Incident Management System structure
•
encourage organizations to develop mechanisms to share critical information with their members during a pandemic.
The toolkit is not intended to provide operational guidance for organizations but to enable them to effectively and efficiently communicate with their members and the Ministry of Health and Long-Term Care regarding operational issues, health and safety matters, communications activities and other pandemic-related topics. Chapter #12A: Communication Tools
Terminology “Organization” (or “sector organization”) denotes the user of the toolkit. It refers to anyone – professional and community organization, health care provider, or labour organization – who may use this toolkit. “Liaison organization” refers to a specific organization that has been designated as a link between the Ministry of Health and Long-Term Care and the organization’s sector. It serves as a conduit for information to and from the MOHLTC. The liaison organization can be designated by mutual agreement of the other organizations in its sector or, in the absence of agreement, by the MOHLTC. Sectors include, but are not limited to: hospitals, physicians, pharmacists, long-term care homes, home-care providers, faith organizations and nurses. “Stakeholder” refers to the external individuals or groups with whom an organization must communicate during a pandemic. Stakeholders include: clients, patients, visitors, member organizations and others.
1. Trigger: When to start using the Toolkit Organizations should constantly monitor provincial indicators for a change in pandemic status or phase. These provincial indicators are available at the Emergency Management Unit of the Ministry of Health and Long-Term Care website at: www.health.gov.on.ca/pandemic. In the case of a pandemic, organizations should implement their crisis plan, at the latest, when this indicator changes to Emergency.
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Figure 1: Provincial Emergency Indicators
The healthcare system is operating under normal conditions. Under these conditions the ministry maintains ongoing surveillance for abnormal events.
An abnormal event, potential or actual emergency has been detected or is in development. Under these conditions the ministry enhances its surveillance and monitoring activities and takes appropriate related actions.
The province is in an emergency response mode. Under these conditions the ministry implements its Ministry Emergency Response Plan (MERP) and activates its Ministry Emergency Operations Centre (MEOC) in order to coordinate the appropriate response activities.
The ministry is working to ensure a smooth transition from Enhanced or Emergency Conditions to Routine Conditions.
In the period leading up to the discovery of pandemic influenza in the province, organizations will receive Important Health Notices (IHNs) advising of the changing situation. Organizations can and should implement their crisis plans when their patients, staff, operations or reputation could be affected. The World Health Organization (WHO) monitors the status of influenza around the world and declares pandemic alert phases based on the number of cases and the modes of transmission of the illness. The WHO pandemic alert phases are updated on: http://www.who.int/csr/disease/ avian_influenza/phase/en/ Organizations can also use the WHO phases as the trigger to implement their crisis plans.
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2.
Crisis Communications Team Roles and Responsibilities
Each organization is expected to have a crisis communication team. Team members should have particular skills and experience that will help them communicate and manage the effects of a pandemic on the organization and its stakeholders. Ideally, crisis communication teams are small and nimble but they have access to additional staff who can gather information and perform duties as required. Each member of the team should have at least one backup designated in the event the core member cannot perform his/her function. Liaison organizations will have their own crisis communications team. In addition, they will act as a conduit of information for their sector. During an influenza pandemic, liaison organizations will take 12A-2
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information provided by the MOHLTC and share it with other organizations in their sector, and they will also coordinate and synthesize information received from their sector and communicate this information to the MOHLTC in a timely, effective manner. The liaison organization is expected to plan and act in the best interest of its sector’s members and stakeholders. Its crisis communications
team members should have the particular skills and experience that will help manage the effects of a pandemic on the organization itself and on its sector’s members and stakeholders. The roles of the crisis communications teams in both sector organizations and liaison organizations are summarized below; positions should be staffed with individuals with appropriate skills.
Table 1: Crisis Team Roles and Responsibilities Type of Role
Sector Organization Responsibilities
Liaison Organization Responsibilities
Communications
Works with senior leadership to liaise with the sector’s liaison organization. Develops key messages/statements. Works with other internal experts (including Joint Health and Safety Committees or Health and Safety representatives) to interpret Important Health Notices (IHN) and directives from MOHLTC for the organization’s stakeholders, and to develop content for internal and external communications. Distributes organization’s materials and information from MOHLTC to members. Communicates with media. Identifies and helps prepare primary and back-up spokespeople. Determines third-party contacts to use as spokespeople. Ensures media monitoring is in place.
Works with command during daily calls with various branches of MOHLTC (communications, operations, and public health). Works with command to communicate information from MOHLTC to the sector’s organizations.
Updates senior leadership.
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Develops key messages/statements. Works with other internal experts (including Joint Health and Safety Committees or Health and Safety representatives) to interpret Important Health Notices (IHN) from MOHLTC for the organization’s stakeholders and the sector’s organizations, and to develop content for internal and external communications. Distributes organization’s materials and information from MOHLTC to members and sector organizations. Communicates with media. Identifies and helps prepare primary and back-up spokespeople. Determines third-party contacts to use as spokespeople. Ensures media monitoring is in place. Updates command.
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3.
Step-by-Step: Communications in a Pandemic
The following is a step-by-step guide to communicating in a pandemic. Figure 3: Communications Preparedness and Response by Pandemic Period
Before a Pandemic: Prepare To ensure clear communications during a pandemic, it is essential to identify information pathways, expectations and reporting mechanisms in advance. Together with other organizations in your
Chapter #12A: Communication Tools
sector, you should determine:
•
which organization will serve as the liaison organization with the MOHLTC (If a sector does not identify a single liaison organization, the MOHLTC will designate one)
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•
how information from the MOHLTC will be delivered to your sector’s stakeholders.
This will help establish who will funnel information into MOHLTC during a pandemic and – when several organizations communicate with the same key audiences – where those audiences should look for updated information. Once the flow of information for your sector is determined, the liaison organization should inform MOHLTC Communications and Information Branch and the Liaison Officer at the MEOC of the planned information flow within the sector. Complete contact information (i.e., for the key liaison person and a back-up) should be provided to the MOHLTC Communications and Information Branch Crisis Team Communications Manager.
members whose skills meet the needs outlined in the roles and responsibilities outlined above. Step 2: Manage Plan According to the MOHLTC Information Cycle
The Ministry of Health and Long-Term Care has created a 24-hour crisis communications clock that outlines the daily information cycle the ministry will follow in the event of a pandemic. To receive information from and share information with the ministry, your organization should tailor its activities to correspond with this clock (see Chapter 12). Gather Information on the Situation
•
Evaluate the current situation’s impact on employees, patients, visitors, and operations. See the situation scan template. Liaison organizations should complete the situation scan in advance of calls with the MOHLTC and advise them of any potential conflict; this means sector organizations must complete the scan for their own operations and share it with their liaison organization in a timely manner. Liaison organizations may consider compiling situation scans for their own operations and for their sector, based on information provided by sector organizations.
•
Plan for the worst-case scenario, laying the foundation for addressing issues that may arise (e.g., staffing shortages, technology failures, supply shortages). See the scenario planning grid.
•
Use the New Information Report to record decisions and to assess the status of actions at the team’s next meeting.
Liaison organizations should advise audiences in their sector about how they will deliver information about a pandemic and what their expectations are regarding the use of that information. For example:
•
Are audiences in your sector expected to communicate the information to others?
•
If so, in what form, and when?
•
Are audiences in your sector expected to receive and assimilate information and implement activities, as required?
•
Are they required to report back to you?
•
If so, how?
Step One: Get In Front Establish/Convene Pandemic Crisis Communications Team
•
Each organization should establish and convene a pandemic crisis communications team with staff
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•
Use the communications materials created and distributed by MOHLTC to help gather information and plan.
•
Provide contact information for more information, or answer questions.
Identify Internal and External Audiences
Identify Spokespeople
and Enable Information Distribution
•
Identify spokespeople based on their knowledge and experience, their ability to connect with the intended audience, and their ability to deliver information in a clear and direct way. Spokespeople should be calm and reassuring while educating audiences about proper methods of protecting themselves, their families, and those who are ill. The person in the “command” role is often the spokesperson; however, in some cases another member may be better suited to the task.
•
Identify a back-up spokesperson.
Systems
•
Determine who key audiences are, identify the member of the crisis team responsible for communicating with each audience, by what method and when. Enable the systems required to communicate with each audience (i.e., email distribution lists readied, notification sent to stakeholders to receive information). See key audience grid (page 13).
•
Distribute critical information received from MOHLTC to stakeholders. Important Health Notices (IHNs) are intended for health care providers and are distributed through MOHLTC’s email distribution systems, but may not reach all your individual members. Consult your stakeholders to determine if your organization should forward IHNs with practical advice on how to implement the information. Forward IHNs intact, without editing, and provide advice as an introduction. See sample IHN.
Step 3: Communicate Use the content checklist to help ensure your communications address all the information recipients need. MOHLTC will be using a similar checklist to help frame the information sent from the ministry to stakeholders. Communicate with Employees
•
Take the lead role in communicating the details of the situation with employees. Work with Joint Health and Safety Committees or Health and Safety Representatives to communicate the health and safety precautions to be followed to reduce any spread of the virus and to educate employees about their responsibility to help protect themselves, their families, and those who are ill.
•
Use different methods to communicate with employees (e.g., pay envelopes, email, the company intranet, bulletin boards, newsletter, voice recording on a company phone
Develop Specific Key Messages
Key messages communicated should: •
Describe the details of the current situation.
•
Describe the impact of the situation on your stakeholder audience.
•
Describe the action being taken to mitigate the spread of disease and promote treatment.
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•
system). Ensure information is available in languages appropriate to the organization’s workforce. Share IHNs with employees who are health care providers.
communicating in a crisis. Depending on the situation, MOHLTC, the federal government or municipal government(s) will take the lead in communicating about the pandemic to the general public.
Time communications with employees to include the most recent information from MOHLTC.
•
Communicate with Stakeholders
•
Give key messages and communications logs to staff who are handling calls from stakeholders. The log should be used to track calls related to the pandemic.
•
Forward completed log forms to the crisis team as soon as possible to keep members updated on stakeholders’ questions and comments. Use the information to modify key messages. The forms are also helpful when reporting an incident to authorities.
• •
•
Address operational matters during the daily 0830h call. Communication issues may require a separate call.
Communicate with Media
Media relations are a key method of
Chapter #12A: Communication Tools
the situation centres around your operations
•
you have to communicate information particular to your sector (e.g., restricting visitors at hospitals or long-term care facilities, reducing home care services)
•
your operations have received media attention that is perceived as unfair, inaccurate or incorrect.
Plan communications with media with the MOHLTC information cycle in mind.
•
Provide additional communication to the general public through:
Record feedback and share it through the liaison organization with MOHLTC. Communicate operational matters with the MOHLTC through the MEOC. Call the Healthcare Provider Hotline: calls will be directed to the call centre representative with the appropriate expertise to answer the question(s). The hotline number is 1-866-212-2272.
•
•
Include the most recent information from MOHLTC.
•
Engage the media directly when:
•
in-store public address systems
•
posters and pamphlets
•
announcements at meetings
•
existing mailings of newsletters or statements.
Communicate with MOHLTC
•
Funnel information to your sector’s liaison organization, which will act as a conduit for stakeholder information and input to the MOHLTC. See templates that summarize the type of information critical to the MOHLTC.
•
Complete and share (when appropriate) the situation scan, scenario planning grid, the incoming media call report, and the new information report. Provide these completed forms to the liaison organization before the daily 0830h 12A-7
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call, when the liaison organizations will share the sector’s information with the MOHLTC.
•
Complete the key audience grid and work within your sector to avoid duplicate outreach. Liaison organizations will share the outreach plan with the MOHLTC as needed.
Evaluate Incoming Communications
•
Evaluate quickly the types of requests, their tone and the responses required from the communications logs to identify issues to be addressed.
•
Agree within your sector on a deadline to send the list of issues to your liaison organizations – allowing enough time for the liaison organization to summarize them for their regular communications with the MOHLTC. When several organizations identify similar questions or concerns, share this information with the MOHLTC during the daily 0830h call. This information will help shape the tone and content of key messages.
•
Act immediately on stakeholder/employee requests for information.
•
Review MOHLTC communications and evaluate them based on your organization’s needs. Do they contain the right information? Are they in the right format, and in the right languages? Provide feedback through your liaison organization.
Step 4: Evaluate Progress Evaluate Information Delivery, MOHLTC Information, Media Coverage, Stakeholder Response
•
Scan daily newspapers for stories related to the situation.
•
Analyze news coverage for: •
•
Content: key messages used and understood; quotes from your organization’s stakeholders and sector’s organizations; pictures; content placement; page number or time of day. Distribution: the number and location of media outlets that print/broadcast stories.
Communicate New Information
Regular communications will help reduce the spread of influenza, help patients get the treatment they need, and protect employees from illness.
•
Update key messages as new information becomes available and communicate new information to the appropriate stakeholders and audiences.
Chapter #12A: Communication Tools
Update Crisis Toolkit
Update the toolkit to include new internal or external contacts, new systems of communications as they are developed, and new sample communications materials.
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Situation Scan Date:
Activity
How to Address
Communications with MOHLTC via liaison organization Are we connected to the conduit organization to provide them with updates or to receive information from the MOHLTC?
Employee Health and Safety Are we following infectious disease protocols?
Are we following occupational health and safety legislation and advice?
Are we working with the Joint Health and Safety Committee in conducting ongoing risk assessments?
Do we have sufficient personal protection supplies?
Patient Health and Safety Are we following infectious disease protocols?
Are we admitting visitors?
Are we admitting volunteers?
Scheduled External Activities Do we have executives speaking at events?
Do we have an open house or meeting planned
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How to Address
(on or offsite)? Are we conducting media relations for another purpose?
Are we exhibiting at events or tradeshows?
Prolonged Crisis Mode Do we need to increase staff for 24-hour staffing or to accommodate illness?
What is our policy for absenteeism due to illness?
Are we reporting workplace-acquired illnesses to MOL, MOHLTC, and WSIB?
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Scenario Planning Grid
SCENARIO: (e.g., Residents in long-term care homes could get the flu from visitors.)
FACTORS WHICH COULD INFLUENCE ISSUE: (e.g., Sanitizing stations, gloves and masks may reduce risk of transmission; temporarily restricting visitors or volunteers may reduce risk of transmission.)
WORST CURRENT OPERATIONAL THREAT: (e.g., Resident dies from flu introduced by visitor; flu spreads to other residents and employees.)
KEY PUBLICS AFFECTED: (e.g., Residents, their families, employees, volunteers.)
BEST PROBABLE OUTCOME: (e.g., Receive temporary order from MOHLTC to restrict access.)
ACTION TO INFLUENCE: (e.g., Liaise with EMU through provider line and during daily calls to request next steps.)
CURRENT DATE:
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New Information Report
Date:
Time:
Source: Situation and New Information:
Next Steps:
Source Contact: Name: Title: Organization: Business Phone:
Cellular Phone:
Email address:
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Key Audience Grid
Audience
Who’s responsible for contacting them?
Method of contact? (e.g., email distribution, phone, meeting, signs)
By when/ How often?
Other organizations in the sector Employees Joint Health and Safety Committee/Health and Safety Representative Patients Visitors Volunteers Suppliers Government Professional Association Labour Organizations Media
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Communications Log Subject of Communication: Date:
Time:
Stakeholder Contact Information: Name: Title (if known): Company/Organization Name: E-mail address (if known): Telephone (if known):
Fax (if known):
Method of Contact: Incoming Call
Outgoing Call
Letter (attached)
In Person
E-mail (attached)
Fax (attached)
Category: (please tick one): Member Employee
General Public
Government
Other (specify)
Specific Questions:
Other Comments:
Your Response: (include what you said, what was promised and/or what expectations were set for information and deadlines)
Your Assessment of Level of Concern: (tick one) High
Low
Neutral
Your Name/Position:
SEND TO: • • •
Your organization’s crisis team Sector organizations send to their sector’s liaison organization Liaison organizations send to Crisis Team Command
Chapter #12A: Communication Tools
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Incoming Media Call Log ***FORWARD COMPLETED FORMS TO YOUR ORGANIZATION’S CRISIS TEAM MEDIA COMMUNICATIONS CONTACT IMMEDIATELY*** Date:
Time:
Media (name of newspaper, radio/TV station):
Reporter’s name:
Phone: Fax: E-mail: Reporter’s/producer’s deadline: Key questions:
When will the story run?
What information was provided, by whom?
*** Liaison organizations receiving these forms should share the information with the MOHLTC***
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Stakeholder Communications Checklist Content Contains information relevant to your stakeholders:
Hospitals Long-term care facilities Home care providers Doctors Nurses Municipal employees Community support services
Emergency services workers Laboratory employees Pharmacists Physiotherapists Faith/support workers Other health care providers
Includes scientific references for information provided Provides practical direction to a variety of sectors and health care providers based on the information provided Contains information for reaching a contact who can provide clarification
Format Addresses language needs: English French Other _________________________________ Logistics: Created by _____________________________________ Approved by ____________________________________ Distributed by: Email distribution list: ___________________________ Voicemail distribution list: ________________________
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Internal Contact List Name, Title
Phone/Fax
Email
Role
To reach the MOHLTC for clarification on any matter of care or pandemic policy, organizations should phone the MOHLTC Healthcare Providers Hotline at 1-866-212-2272.
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2. Communication Roles/Activities by Pandemic Period and Phase WHO Pandemic/ Phase Interpandemic Period: Phase 1 No new influenza virus subtypes have been detected in humans.
Federal Level Continue to work with partners to improve the F/P/T communication/ information infrastructure. Continue to publish FluWatch bulletins. Continue to provide accurate updates on influenza and the pandemic phase for the public and health care workers/ stakeholders.
Provincial Level
Local Level
Continue to actively promote UIIP to the public and health care workers.
Work with professional organizations and labour associations to actively promote UIIP to the public and health care workers. Ensure all educational materials for the public and health care workers/ stakeholders on influenza are accurate, up-to-date and accessible (i.e., languages, literacy levels). Continue to reinforce the importance of prevention/ mitigation activities. Continue to work with MOHLTC to improve the communication/ information infrastructure. Work with MOHLTC to establish procedures to ensure all information is accurate at the time it is released.
Ensure all educational materials on influenza and preventive/ protective practices for the public and health care workers/stakeholders are accurate and up-to-date. Continue to reinforce the importance of prevention/ mitigation activities. Continue to work with federal government and other P/Ts to improve the communication/ information infrastructure. Run annual pandemic simulation exercise and use results to refine MOHLTC Crisis and Risk Communications Response Plan. Work with PHAC and HUs to establish procedures to ensure all information is accurate at the time it is released. Establish performance measures that can be used to evaluate communications activities during a pandemic.
Interpandemic Period: Phase 2
Continue Phase 1 activities. Respond to any media enquiries about the risk.
Continue Phase 1 activities.
Continue phase 1 activities.
Continue Phase 2 activities.
Continue Phase 2 activities.
Continue Phase 2 activities.
Review and, if necessary, refine F/P/T communications plan.
Review and, if necessary, refine F/P communications plan and MOHLTC Crisis and Risk Communications Response Plan; ensure plans are still consistent with Ontario’s emergency response plan. Alert Crisis Communication Team to be on standby. Hold background technical briefings for government, media, external experts, professional organizations, and other stakeholders. Ensure: • Telehealth and EMU call centre staff have up-to-date information. • rapid 24-hour translation capability is in place and all responders know how to access this resource.
Review and, if necessary, refine local communication plans; confirm when and what to communicate to the public, health care workers, workplaces, and other audiences, focusing on existing influenza prevention messages and WHO/PHAC updates.
A circulating animal influenza virus subtype poses a substantial risk of human disease. Pandemic Alert Period: Phase 3 Human infection(s) with a new subtype, but no human-tohuman spread or spread to a close contact only.
Chapter #12A: Communication Tools
Review and, if necessary, update pandemic contact list.
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Federal Level Continue Phase 3 activities.
Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.
Pandemic Alert Period: Phase 5 Larger cluster(s) but human-tohuman spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible. Pandemic Period: Phase 6 Increased and sustained transmission in general population.
Provincial Level
Local Level
Continue Phase 3 activities. Confirm that key stakeholders have appropriate technology to access provincial information. Confirm provincial spokespeople and backup personnel for a pandemic and provide crisis communication training. Verify lists of stakeholder and media contacts. Confirm translation requirements.
Continue Phase 3 activities. Confirm local spokespeople and backup personnel for a pandemic and provide crisis communication training. Verify lists of stakeholder and media contacts. Confirm translation requirements.
Review and, if necessary, revise educational materials about infection control in homes, schools and workplaces. Develop fact sheets, briefing notes and media communications templates in appropriate languages. Work with public health to develop public education messages. Work with provinces to develop key messages. Review and, if necessary, revise educational materials and guidelines for public health partners and the general public. Activate Crisis Communications network.
Work with PHAC to develop key messages. Activate Crisis Communication Plan, Team and network (i.e., MOHLTC, PHAC, public health units, health associations). Provide regular updates using Important Health Notices and website postings, including new/updated case definitions and clinical guidelines. Implement plans to communicate with all relevant audiences, including the media, key opinion leaders, stakeholders, employees.
Work with MOHLTC to develop public education messages, and define the role of spokespersons. Participate in Crisis Communication network.
Provide information updates to provinces. Work with Ontario to hold media and stakeholder briefings with local MOHs, provincial officials and other officials as required.
Provide daily briefings to four key audiences, including indepth technical briefings for the media when necessary. Initiate regular conference calls with Health Care Stakeholder Council.
Activate Crisis Communication Plan. Distribute fact sheets. Continue regular communication with communication partners. Provide information in real time to health care workers, media and the public regarding Ontario’s: • level of readiness • possible decreases in service • alternative care sites. Provide regular updates to Joint Health and Safety Committees and receive updates from them as appropriate. Update annual multimedia campaign promoting UIIP, adding information about current influenza activity.
Continue regular communication with communications partners. Work with PHAC to hold media and stakeholder briefings with local MOHs, provincial officials and other officials, including MOHLTC senior management, as required. Provide regular information/ updates in real time to health care workers, media and the public regarding Ontario’s: • level of readiness • possible decreases in service • alternative care sites.
Implement plans to communicate with all relevant audiences, including the media, key opinion leaders, stakeholders, and employees.
Review and, if necessary, revise Telehealth and Infoline
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Ontario Health Plan for an Influenza Pandemic August 2008 WHO Pandemic/ Phase
Federal Level
Provincial Level
Local Level
messages. Continually update website information. Update annual multimedia campaign promoting UIIP, adding information about current influenza activity. Pandemic Period: Phase 6 cont. Regional and multi-regional epidemics.
Pandemic Period: Phase 6 cont.
Continue to work with P/Ts to provide consistent messages. Monitor effectiveness of communication strategy and modify as required.
Continue to work with PHAC and HUs to provide consistent messages. Continue to implement Crisis and Risk Communication Response Plan.
Continue to work with MOHLTC to provide consistent messages. Continue to provide information/ updates to health care workers, the media and the public.
Continue to provide information/ updates to health care workers, the media and the public. Gather information from the field and use that to inform/refine the communications plans. Monitor effectiveness of provincial communication strategy and modify as required.
Gather information from the field and use that to inform/refine the communications plan. Monitor effectiveness of local communication strategy and modify as required.
Evaluate federal communications response.
Identify lessons learned.
Identify lessons learned.
Evaluate provincial communications response. Update public and provide education materials, including scripts for Infoline, Telehealth and public advertising.
Evaluate local communications response.
Revise pandemic communications plan based on experience.
Revise pandemic communications plan based on experience.
Revise pandemic communications plan based on experience.
Return to Phase 1 activities.
Return to Phase 1 activities.
Return to Phase 1 activities.
End of First Pandemic Wave; Pandemic Subsiding. Postpandemic Period return to Phase 1
Chapter #12A: Communication Tools
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3. Sample Important Health Notice
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Ontario Health Plan for an Influenza Pandemic August 2008
13. Public Health Services Public health was and is where the largest numbers of lives are saved, usually by understanding the epidemiology of a disease – its patterns, where and how it emerges and spreads – and attacking it at its weak points. This usually means prevention. … Public Health measures lack the drama of pulling someone back from the edge of death, but they save lives by the millions. The Great Influenza, John M. Barry
Public health units will play a key role in all pandemic periods. They also play an essential role in providing other services that protect the public from a range of other diseases and health risks, and many of these services would have to be maintained during a pandemic. The Capacity Review of Ontario’s public health system highlighted the shortages and gaps in the public health system now, and recommended changes that will help ensure all health units across the province have the “critical capacity for improved effectiveness and emergency and surge response.” This section describes the influenzarelated services public health provides, and provides a framework for planning and managing public health services during an influenza pandemic.
13.1 Influenza Services During the Interpandemic and Pandemic Alert Periods During the interpandemic period, public health services/activities include:
• promoting and managing the seasonal influenza immunization program
• year-round surveillance of •
influenza-like illness (ILI)
•
institutional respiratory outbreaks
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•
laboratory reports/integrated Public Health Information System (iPHIS)
•
influenza vaccine coverage rates in hospital staff, long-term care home residents/staff
•
adverse vaccine reaction reporting
• providing education for health care workers, health care settings and the public
• working with provincial and federal public health authorities to develop policy on influenza immunization, outbreak management and preparing for health emergencies. (For more information on these activities, see Chapters 5 and 6.) In the late pandemic alert period, particularly when the only influenza cases in Ontario are imported cases (i.e., people arriving in Canada from a country with influenza clusters) public health units will use aggressive measures to slow the spread of the virus and buy some additional time:
• case and contact follow up • education, communication • reinforcing risk reduction strategies (For more information on public health measures, see Chapter 6.)
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13.2 Services During the Pandemic Period In the event of a pandemic (Pandemic Phase 6), health units will be expected to play a major role in coordinating the local response. This will put intense pressure on health unit resources (human, financial, physical), and health units will have to determine the most effective way to use their resources. Influenza-related Activities In terms of influenza-related activities, health units will continue most prepandemic public health activities during the pandemic phase as appropriate; however, case and contact follow up will be discontinued and surveillance activities will be modified (See Chapters 5 and 6). Health units will focus on education, communication (local information hotline), implementation of community based public health measures, institutional outbreak management and surveillance activities. Other Public Health Programs and Services During a pandemic, health units may have to “scale back” some other programs and services (including mandatory health program activities) in order to meet influenza-related needs. Pandemic plans prepared by health units will include resource reallocation/ redeployment plans that will:
• identify the additional activities required during a pandemic
• determine which critical services/program components must be continued throughout the pandemic
• identify local staff who could be recruited/redeployed without jeopardizing delivery of identified key services/program components
• manage workloads for all staff: those involved in pandemic activities and those responsible for routine public health services/activities
• prioritize work/requests for nonemergency services
• streamline the “wind-down” phase of the pandemic by bringing back services in order of importance to public health needs.
13.3 Planning Non-Influenza Activities During a Pandemic To ensure some consistency across the province in the availability of public health services during a pandemic, OHPIP has identified four levels of program components/activities in a public health unit: 1.
Must Do – critical services, cannot be deferred or delegated
2.
High Priority – do not defer if possible or bring back as soon as possible
3.
Medium Priority – can wait if pandemic is not too long
4.
Low Priority – can be brought back when the pandemic is over.
Table 13.1 includes examples of services/ program components that should be considered when ranking priorities and developing a scale-back plan.
• identify activities that can be reduced or curtailed
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Table 13.1: Examples of Public Health Program Components to Consider Maintaining/Curtailing Program/Service
Consider Maintaining
Consider Reducing or Curtailing
Routine vaccinations programs
infant primary series
other routine vaccination programs
Tuberculosis program
active case follow-up and outbreak management
other activities
Vaccine preventable diseases
case management of specific VPDs (e.g., meningitis, measles, rubella)
other activities
Travel clinics
for urgent and unavoidable travel
for non-urgent travel needs
School programs
pandemic related activities
other activities
STI programs
case management and contact tracing
other activities
Sexual health programs
urgent birth control services
other activities all activities
Injury prevention programs
When deciding which activities are “must do” or “high priority” and which ones are “medium” to “low” priority and can be scaled back during a pandemic, public health units will use the Ethical Framework for Decision Making (see Chapter 2). They will also consider the following factors for identifying both critical services that must be maintained and services that could be reduced or curtailed. Factors to Consider When Ranking the Priority of Public Health Services Public health programs/activities that have one or more of the following factors must continue to be provided during a pandemic:
• The activity is mandated by legislation to be directly provided by public health within a specified time frame AND addresses a high health risk. For example: •
Does the activity involve a health hazard, or is it likely to be a health hazard, requiring same day assessment and initiation of action within 24 hours?
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•
Does the activity involve an assessment of a reported suspect/confirmed infectious disease case/outbreak?
•
Does the activity involve an assessment of a high risk mother requiring a first response within 24 hours?
•
Does the activity involve a potential for “rabies transmission”?
•
Does the activity involve a response to an adverse drinking water test result that requires immediate action in accordance with Ontario Drinking Water Standards?
• The activity is required at certain times of year or at a certain point in the disease/illness cycle. For example: •
will not providing the service at a certain time endanger citizens’ health and safety (e.g., post exposure prophylaxis for blood borne exposure, providing
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emergency contraceptive medication)?
• The activity is necessary to eliminate an imminent threat to public health or the health of an individual exposed to the threat.
• There is a high risk of legal liability if the intervention is not provided in a timely way (i.e., duty of care). For example: •
If the service were not provided, would it constitute negligence?
•
Will not providing the service endanger citizens’ health and safety?
Factors to Consider When Developing a “Scale Back” Plan The number of public health services that have to be scaled back and the extent to which they are reduced or curtailed will depend on the phase and severity of the pandemic. When developing and implementing their plans, public health units will take into consideration:
• the epidemiology of the outbreak locally/regionally (i.e., burden of illness, mortality, impact on certain populations, pandemic “priority groups”, health care worker illness/absenteeism)
• absenteeism of public health staff due to illness and family caregiving
• coverage for “single incumbent” positions, such as the Medical Officer of Health
• local public health capacity, including ability to reallocate/redeploy resources (e.g., from non-communicable disease to communicable disease control); to off-site locations (e.g., working from home)
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• local needs including skill sets, financial and physical resources needed for pandemic activities (i.e., surveillance, antiviral distribution, mass vaccination clinics, case management, public health measures and urgent/non-urgent communication with health care professionals, other key stakeholders in pandemic management and the public) as well as those required to maintain other “must do” and “high priority” programs and services
• the potential increase in demand for public health services at different stages of the pandemic response (e.g., as soon as a vaccine becomes available, two to three million doses of vaccine will have to be administered each month until Ontario’s population is fully immunized)
• local health care, emergency response and social support capacity
• the “spin-off” effects of scaling down or suspending certain programs/activities
• the availability of assistance from other jurisdictions (staff and resources may be redeployed in earlier phases as well as the pandemic phase to respond to pandemic needs)
• direction or guidance from provincial or federal governments.
• the potential impact of repeated waves (e.g., the priority of some medium or lower ranked activities may change over time). More work will be done at the provincial level, in consultation with local health units and other stakeholders (i.e., schools, hospitals, long-term care homes, professional associations), to identify – by
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program/service area and by program component – activities that can be scaled back during public health emergencies such as an influenza pandemic. See the MOHLTC website for a breakdown of the estimated impact of an influenza pandemic by attack rate for each public health unit catchment area: www.health.gov.on.ca/pandemic.
Chapter #13: Public Health Services
13.4 Next Steps The public health system will continue to develop plans for public health services during a pandemic, taking into account the impact of the recommendations of the Capacity Review Committee and the current review of Mandatory Public Health Programs and Services.
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14. Laboratory Services Laboratories everywhere had turned to influenza. … In Germany, in Italy, even in revolutiontorn Russia, desperate investigators searched for an answer. But by the fall of 1918 these laboratories could function only on a far-reduced scale. Research had been cut back and focused on war. … Laboratories in both Europe and the United States were affected, but Europeans suffered far more, with their work limited by shortages not only of people but of everything from coal to heat to money for petri dishes. The Great Influenza, John M. Barry
In the event of an influenza pandemic, Ontario laboratories will play a significant role in the detection, surveillance and characterization of the influenza virus. Laboratory confirmation of pandemic influenza in a person, or within the population, in Ontario or Canada, will trigger many of the planned pandemic responses, including the initiation of various public health measures and the use of anti-viral agents. Laboratory testing takes place within three distinct yet highly interrelated health service settings: hospital laboratories, public health laboratories and community laboratories. The National Microbiology Laboratory (NML) in Winnipeg will play a key role in confirming the presence of the pandemic strain in Ontario and in ensuring timely exchange of laboratory surveillance and scientific information among all levels of government. This laboratory houses Canada’s only Containment Level 4 laboratory. The information provided in the Laboratory chapter of the 2008 OHPIP has been written in the form of “guidelines” only, in order to give the user some flexibility, acknowledging that laboratories must rely on professional expertise and experience once a pandemic arises. As of the writing of this text, the exact nature of the influenza agent responsible for the next pandemic is unknown. The guidelines have been developed based on currently available scientific knowledge, experience with interpandemic influenza strains, and on information collected and derived from previous pandemics Chapter #14: Laboratory Services
and currently circulating strains with pandemic potential.
14.1 Objectives • To assist laboratories preparing for a pandemic through the provision of guidelines and planning tools.
• To identify the laboratory services required during a pandemic and those that can be curtailed.
14.2 General Guidelines for Pandemic Planning Influenza is a zoonotic disease, and currently the largest natural public health threat to humans. All mammalian influenza viruses, including those that infect humans, are maintained in birds, the natural reservoir for influenza A viruses. Other animals, typically pigs, can also play a role in the emergence of new and potentially pandemic influenza A strains, by providing a vessel for viral reassortment. Recently, human infection with avian influenza A/H5N1 virus has heightened awareness and the potential for the emergence of a pandemic influenza strain. In response to this threat, Ontario laboratories are working to increase laboratory capacity to identify influenza and then detect emerging pandemic strains early. Although much attention and investigation has focused on influenza A/H5N1, these guidelines are also applicable to other future pandemic
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threats, such as those possibly posed by H9 or the highly pathogenic H7, or any other influenza type which may arise with pandemic potential. These guidelines address pandemic influenza virus threats, in general, and not human infection with avian influenza A/H5N1 or other avian influenza types. (See Chapter 14A:
Laboratory Tools - Laboratory Information— Avian Influenza—Interim Guidelines). For additional information on avian influenza infection in humans, please see the Laboratory Annex, Canadian Pandemic Influenza Plan at http://www.phac-aspc.gc.ca/cpip-pclcpi/.
Table 14.1: Overview of Pandemic Responsibilities by Laboratory Type WHO Pandemic/ Phase Interpandemic Period: Phase 1 No new influenza virus subtypes have been detected in humans. Phase 2 A circulating animal influenza virus subtype poses a substantial risk of human disease.
All Laboratories
Provincial Public Health Laboratories
Develop a laboratory preparedness plan to support the response to an influenza pandemic, which addresses laboratory services, operational requirements and human health resources. Assess and address laboratory surge capacity, including human resources, infrastructure, testing, supplies and equipment. Educate and train personnel for pandemic influenza response, including updates on scientific information as it becomes available, bio-safety guidelines and management of respiratory specimens during an influenza pandemic. Develop suspended testing guidelines and testing algorithms, which include those services considered essential during a pandemic, in order to address anticipated human resource and laboratory supply shortages in the event of a pandemic, as well as a surge in testing requests for specimens submitted because of respiratory illness. Maintain essential routine laboratory diagnostic services and surveillance for influenza. Initiate training and crosstraining of laboratory personnel in order to ensure a rapid, expert laboratory response, even in the face of decreased numbers of personnel. Develop and practice emergency response protocols. Survey all laboratory employees for annual influenza vaccine uptake and encourage vaccination of all personnel. Assess the need for anti-viral stockpiling for chemoprophylaxis on site.
As per All Laboratories, plus the following: Implement molecular diagnostic methods for influenza virus, and training, if not already in place. Ensure laboratory participation in proficiency testing programs for molecular based and other testing. Participate in laboratory-based surveillance testing programs, and ensure adequate and representative specimens are forwarded to the National Microbiology Laboratory (NML) as per their direction. Engage and maintain research in support of efficient and rapid diagnosis and study of influenza viruses. Disseminate precise and accurate communications to clients, stakeholders, employees and other laboratories.
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National Laboratory Monitor preparedness and laboratory capacity for seasonal influenza. Continue to provide and/or develop anti-viral susceptibility testing methods. Transfer sub-typing and susceptibility testing expertise/methodology to designated Public Health Laboratories as appropriate. Develop, evaluate and provide reagents such as RNA controls and monoclonal antibodies to Public Health Laboratories as appropriate. Provide on-going direction regarding laboratory based surveillance programs. Disseminate precise and accurate communications to Provincial and Territorial (P/T) laboratory partners.
Adopt testing and reporting and surveillance protocols from the NML and PHAC for influenza diagnosis, etc. as available.
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Ontario Health Plan for an Influenza Pandemic August 2008
WHO Pandemic/ Phase
All Laboratories
Pandemic Alert Period:
As per interpandemic period, if not already implemented, plus the following:
Phase 3 Human infection(s) with a new subtype, but no human-tohuman spread or spread to a close contact only.
Review operational and other plans to manage increased number of requests for influenza testing. Ensure clearly labeled specimens from patients with suspected novel influenza are sent to the National Microbiology Laboratory or P/T Public Health Laboratories. Survey all laboratory personnel for annual vaccine uptake. Consider institution of active surveillance for influenza-like illnesses (ILI) among laboratory personnel. Ensure guidelines for specimen type, collection, transportation and testing, as provided by National and Provincial Pandemic guidelines, are implemented. Review priorities for testing and initiate plan to suspend testing for non-essential laboratory services. Enact pandemic plans as needed.
Phase 4 Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans. Phase 5 Larger cluster(s) but human-tohuman spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible. Pandemic Period: Phase 6
All of the above.
Increased and sustained transmission in general population.
Chapter #14: Laboratory Services
Provincial Public Health Laboratories
National Laboratory
As per interpandemic period, plus the following: Under National direction, enhance laboratory-based surveillance of influenza virus subtypes. Ensure clearly labeled and appropriate specimens from patients with suspected novel influenza are sent to the National Microbiology Laboratory (NML) or other P/T Public Health Laboratories. Ensure increased capacity for molecular diagnosis of influenza. Rapidly communicate information regarding identification of novel influenza sub-types to NML and submit to NML for confirmation. Inform Medical Director immediately if novel influenza sub-type is identified. Culture of novel subtypes of influenza viruses should be carried out in CL-3 facility. Ensure laboratory protocols are communicated as they evolve to all provincial and other influenza testing laboratories. Monitor anti-viral resistance. Enact operational and other plans to manage increased number of requests for influenza testing.
As per interpandemic period plus the following: Provide technical support to the Public Health Laboratories and Ministries of Health and Agriculture, as requested, by providing confirmatory testing and analyzing novel influenza virus subtypes – including avian isolates and human isolates with pandemic potential, including sub-typing, RNA sequencing, and drug sensitivity testing. Work with Provincial Public Health Laboratories to ensure that the diagnostic reagents required for the identification of “pandemic alert” strains are available and are used safely and effectively. Provide guidance on containment and safe handling of respiratory specimens obtained from potential cases of pandemic influenza. Work with provincial laboratory partners to ensure appropriate surveillance guidelines are in place and enacted. Regularly and routinely engage in pandemic drills.
Submit select specimens from possible pandemic influenza patients to Provincial Public Health Laboratories designated as influenza testing sites or to National Microbiology Laboratory, as appropriate. Distribute updated guidelines on all aspects of specimen management and diagnostic testing to healthcare providers and hospital and community laboratories, as appropriate. Work with national partners to monitor the pandemic virus and conduct special studies as required, or to address other aspects of the response. Ensure communication with employees, clients and stakeholders is clear, precise and up to date.
Work with provincial and global partners to characterize new pandemic viruses including subtyping, RNA sequencing, and anti-viral sensitivity, and to monitor changes over time. Work with provincial public health laboratories to ensure the availability and the safe and effective use of diagnostic tests and reagents. Conduct reference/confirmatory testing for positive samples, and perform viral culture. Culture will be particularly important at the beginning of the pandemic wave (to confirm entry of the pandemic strain in Canada and to obtain baseline information on viral characteristics) and again, as the wave subsides, in order to detect the emergence or reemergence of other respiratory viruses in the population. Take lead for research and investigation of pandemic
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WHO Pandemic/ Phase
All Laboratories
Provincial Public Health Laboratories
National Laboratory influenza virus, including development of improved diagnostic methods, sequencing, anti-viral sensitivity testing, immune response, etc. Update surveillance guidelines as appropriate. Provide accurate scientific information and updates to guidelines as available.
Postpandemic Period: Return to Phase 1
Evaluate pandemic response. Revise pandemic response and protocols, as appropriate. Conduct special post pandemic viral studies, as appropriate.
For a list of pandemic planning activities by laboratory sector in Ontario (i.e., hospital, community and public health) see Chapter 14A: Laboratory Tools.
14.3 Guidelines for Hospital Laboratories It is difficult to predict the impact of an influenza pandemic on hospital laboratory services. Given that there are significant differences in the breadth and depth of laboratory services provided in an academic or teaching hospital and those provided in a community hospital, it is not practical to identify a single list of tests that should or should not be performed during a pandemic. However, hospital laboratories should develop their own list of services (prioritized based on the current services they provide and the patient population they serve). This prioritized testing algorithm can then be used to determine human and laboratory resource requirements in the event of a pandemic. The primary role of hospital laboratories is to support the acute care provided in their facilities. The types of tests that may be reduced or curtailed will depend on the care needs of each facility’s patients. Where possible, planning should be coordinated with other laboratories in the region. Hospital laboratories are discouraged from introducing new or novel Chapter #14: Laboratory Services
testing during a pandemic given the potential lack of resources necessary to carry out appropriate validation procedures. Hospital laboratories should maintain all services required to safely and optimally manage all hospitalized patients within their facility. In the event of a pandemic, it is likely that only the most acutely ill patients will be admitted and cared for in the hospital setting and elective procedures will be postponed. While acutely ill patients may require significant laboratory testing, the decrease in elective procedures and admissions should decrease the overall need for laboratory testing. At the same time, as the mortality rate of the acutely ill patients may be quite high, there may be an increased demand for hospital morgue and autopsy services. Hospital laboratory plans may wish to address these and other related issues. In preparation for a possible pandemic, hospital laboratories should review and develop appropriate plans for all laboratory disciplines (e.g. pathology, chemistry, hematology, microbiology, etc.). See Chapter 14A: Laboratory Tools - The Laboratories Pandemic Planning Self Assessment Tool. Planning should address, but 14-4
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14.4 Guidelines for Community Laboratories
not be limited to:
• human resources • specimen collection, processing and testing • equipment and supplies and storage space • biosafety and biocontainment • contingency and collaborative plans • communication and education of employees and clients
• transportation requirements • operational issues.
Ontario’s community laboratories have identified a suggested list of tests that would be required to support the provision of basic health care to the population as a whole and to those affected by influenza (see Table 14.2). The list of suggested tests varies depending on the severity of the pandemic. During a pandemic with a low attack rate, most routine tests would continue to be conducted. During a pandemic with a moderate or severe attack rate, some routine testing could be reduced or temporarily suspended to increase capacity for other testing.
Table 14.2: Community Laboratory Activity by Severity* of the Pandemic Low (15%) Attack Rates
Moderate (25%) Attack Rates
High (35%) Attack Rates
Continue most testing; suspend or reduce routine screening tests to free up laboratory capacity or address resource shortages
Maintain capacity to provide essential tests, and, depending on capacity and resource availability, continue other testing
Maintain capacity to provide tests required to support basic medical care for population
Continue most testing The following routine and screening tests could be reduced or temporarily suspended if necessary: • HDL cholesterol • TSH • Cervicovaginal specimen – Pap testing • Vitamin B12 • Ferritin • Cholesterol Total • Triglycerides • Folate • Target Drugs of Abuse • Estradiol • Drugs of Abuse • Drug Screen
Provide all required tests listed for severe attack rate PLUS: • anti-HAV IgM • HBsAg • Stool Culture • Cervical Culture • Throat Culture • Glycosylated Haemoglobin • Sputum Culture
Provide the following tests required for basic medical care: • CBC • INR • Sodium • Potassium • Calcium • Chloride • ALT (SGPT) • Glucose • Urinalysis (dipstick only) • Creatinine • Blood Culture • Wounds • Bilirubin (for neonatal assessment only) • HBsAg (for needlestick follow-up only) • Anti-HCV (for needlestick followup only) • TSH to diagnose hyperthyroidism (if required) • Tests required to monitor patients on therapeutic drugs (e.g., antiepileptics) • Selected histology specimens (e.g., suspected melanomas)
*Note: For purposes of this table, severity refers to attack rates (i.e., 15%, 25%, 35%), but this is not the only factor that will determine severity. A low (15%) attack rate of a highly virulent influenza strain that causes more secondary complications and high mortality rates would create the same kind of “severe” demands on laboratory services as a less virulent strain with a higher attack rate. The laboratory system’s response will be driven by the demands for testing created by the pandemic. The intent is to maintain the services required to respond to the population’s medical needs. Community laboratory directors may be contacted to address and approve requests for tests which fall outside of this testing protocol.
Chapter #14: Laboratory Services
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14.5 Guidelines for Public Health Laboratories The province’s public health laboratories conduct virology and other microbiology related testing to:
• support surveillance for, and detection of, emerging and reportable infectious diseases
• aid in the care and treatment of patients • track disease emergence and spread within Ontario.
community laboratories. During a pandemic, laboratory resources may have to be redirected in order to meet the demand for influenza related diagnostics and care. The capacity of all laboratories to maintain current levels of service during a pandemic will depend in part on the availability of laboratory and human health resources at the time. In anticipation of limited resources, the following suspended testing guidelines have been developed for the Ontario Public Health Laboratories (see Table 14.3).
These laboratories also serve as reference and routine testing centers in support of hospital and Table 14.3: Recommended Public Health Laboratory Activities by Severity* of the Pandemic Note: This table is a guide only. Generally, those tests not listed will not be offered. Additional testing will be performed as requested by the Medical Officer of Health or as deemed necessary by infectious disease specialists and microbiologists. Low (15%) Attack Rate
Moderate (25%) Attack Rate
High (35%) Attack Rate
Most testing continues to be offered except screening tests in low risk populations
A number of tests continue to be offered, as human and other resources allow
Testing performed primarily for diagnostic purposes
Influenza Testing (Molecular/Other)
Yes
Yes
Yes
Mycobacterium tuberculosis
Yes
Yes
Yes
CSF, Joint, Pleural, other sterile fluids, etc. culture.
Yes
Yes
Yes
HIV (including viral load)
Yes
Serology only
Serology only
Direct Testing RSV and Rotavirus
Yes
Respiratory only
Respiratory only
ELISA for C. difficile Toxin
Yes
Yes
No
Virus Culture
Yes
Yes
Yes
NAAT for C. trachomatis and N. gonorrhea
Yes
Yes
Yes
Hepatitis (Diagnostic Only)
Yes
Yes
Yes
Malaria, Babesia, Critical Specimens (e.g. CSF)
Yes
Yes
Yes
B. pertussis
Yes
Yes
Outbreaks only
Throat Culture
Yes
Yes
No
West Nile Virus/Arboviruses
Yes
Yes
No
Diagnostic Serology
Yes
Yes
Yes
Prenatal Screening
Yes
Yes
High risk populations
TEST
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only Syphilis
Yes
Yes
Yes
Specimens related to the investigation of Bioterrorism
Yes
Yes
Yes
Sputum Culture and Smear
Yes
No
No
Stool Culture
Yes
Yes
Outbreaks only
Mycology Culture for invasive and normally sterile sites
Yes
Yes
Yes
Antibiotic Sensitivity
Yes
Critical specimens ONLY
Critical specimens ONLY
Chlamydia Culture
Yes
Sexual assaults only
Sexual assaults only
Water Testing, on order of Medical Officer of Health
Yes
Yes
Yes
*Note: For purposes of this table, the severity of the pandemic is by attack rates (i.e., 15%, 25%, 35%), but this is not the only factor that will determine severity. A low (15%) attack rate of a highly virulent influenza strain that causes more secondary complications and high mortality rates would create the same kind of “severe” demands on laboratory services as a less virulent strain with a higher attack rate. It is assumed that those tests not listed will not be offered, unless approved by the Laboratory Director or the Medical Microbiologist(s).
14.6 Influenza Testing in the Event of a Pandemic
far north may be difficult to reach, particularly in winter months)?
Given the large number of people who will be affected by a pandemic and the potential severity of illness, there will be a significant increase in the number of specimens submitted for testing in support of influenza diagnosis. At the same time, there will be a decrease in the available laboratory workforce, due, for example, to personal illness or illness within families.
3. Does the site have adequate numbers of personnel to train and cross-train (e.g. given the anticipated absenteeism rates)?
As entire laboratories may be rendered nonoperational when the influenza pandemic hits their region or city, a minimum of four public health laboratories in Ontario have the capacity for complete and rapid influenza diagnosis and typing using molecular methods. Selection of these four or more sites is based upon several considerations and not upon geographic location alone. For example:
5. Does the laboratory serve a relatively large proportion of the population that is not otherwise served, or could be served, by federal institutions or other local (e.g. hospital virology laboratories) institutions?
1. Does the site have additional available local expertise, (e.g. University, Academic Health Science Centre, College)? 2. Is the site relatively accessible by ground and air, regardless of season (e.g. sites located very Chapter #14: Laboratory Services
4. Do potential human resources exist locally that could fulfill the need for additional personnel (e.g. Medical Laboratory Technology students, University students, Medical or Nursing students)?
6. Is the site physically remote (e.g. greater than 200 km) from other designated testing sites? Sites in close physical proximity may suffer the same human resources, transportation, supplies, and other issues, should pandemic influenza strike their region. As of the writing of this document, there are four public health laboratories in the province equipped for molecular testing, with validated 14-7
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testing available and trained technologists at each of these four sites. Further, in addition to the four designated sites, it is advisable to support an additional site within Ontario dedicated to the molecular characterization of the virus, including sequencing, anti-viral sensitivity testing, and research and development. Although culture for diagnosis of influenza will not be routinely offered during a pandemic, this particular facility will require a certified CL-3 laboratory in order to propagate virus for study. Given that manipulations involve growth of the novel agent, this should not be performed in the same laboratory that is simultaneously culturing material that may contain interpandemic, seasonal human influenza. Culture should be limited to virus in specimens already identified, for example by other Public Health Laboratories, as being of a novel or pandemic strain. Culture in these instances would be for the purpose of further characterization (e.g. antiviral resistance testing) and study of the virus. Moreover, the National Pandemic Influenza Laboratory Preparedness Network (PILPN) has identified the need for additional laboratories across Canada with pandemic influenza expertise, to support National Laboratory partners during a potentially overwhelming pandemic period. Finally, all other public health laboratories should have, at minimum, the capacity to screen specimens by molecular methods for the pandemic strain (e.g. molecular detection of the pandemic strain hemagglutinin). These laboratories should receive training in RT-PCR protocols for the molecular detection of H1, H3, H5, H7 and possibly H9 sub-types. This will ensure adequate surge in the system in the event of a pandemic as well as ready these laboratories for current molecular testing of routine pathogens. Similarly, molecular methodology should be introduced into hospital virology laboratories not yet molecular ready.
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The use of standardized protocols, as developed, validated and distributed by NML, is preferred, and laboratories should participate in molecular proficiency testing programs and incorporate RT-PCR or real time RT-PCR into standard influenza laboratory activities. All specimens that test positive for pandemic or novel influenza strains would then be forwarded to the previously identified full service public health laboratory sites for further testing and molecular sub-typing. In addition, particularly early in the pandemic period, specimens will be forwarded to the National Microbiology Laboratory (or designate) for confirmation, as well as for the purpose of additional viral studies. The Pandemic Influenza Laboratory Preparedness Network (PILPN), under the Pandemic Influenza Committee (PIC), has developed guidelines for “The Minimum requirements for the provision of public health laboratory services during pandemic influenza”, which can be found in Appendix B of the Laboratory Annex of the Canadian Pandemic Influenza Plan (CPIP) at http://www.phacaspc.gc.ca/cpip-pclcpi/. Description of Laboratory Tests for Influenza Virus Laboratory diagnosis of influenza has evolved significantly over time, such that efficient, highly sensitive testing methodologies are now widely available. These accurate, rapid methods are critical to the current methods of management of outbreaks, illness, prevention, containment, and surveillance. Laboratories in the province of Ontario, within the public health and hospital sectors, routinely offer a variety of tests for the detection of interpandemic influenza strains including: rapid antigen testing, nucleic acid based amplification, virus isolation, immunofluorescence testing and serology. To support the rapid diagnosis of influenza A virus infection, laboratory test results should be available within 24 hours. 14-8
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Nucleic Acid Testing (NAT)
The Ontario Public Health Laboratories offer reverse transcriptase polymerase chain reaction (RT-PCR) as the NA test of choice for the screening and sub-typing of influenza viruses. Several hospitals are also able to offer RT-PCR or NAT methods for influenza diagnosis. In the event of a pandemic, NAT will be the mainstay of laboratory based influenza diagnosis given that NAT is considered to be the most sensitive and specific and can be adapted to robotic systems with high throughput capacity and a relatively short turnaround time. Updated protocols will be made available through the National Microbiology Laboratory. Immunofluorescent Assays
Direct fluorescent antibody (DFA) or immunofluorescence antibody (IFA) assays require that respiratory epithelial cells acquired through the specimen collection process are deposited onto a slide and subsequently labeled with monoclonal antibodies conjugated directly or indirectly (via a second antibody) to a fluorescent dye prior to visualization by fluorescence microscopy. Sensitivity and specificity depend upon the quality and type of sample and the number of infected epithelial cells fixed onto the slide. DFA and IFA may enable rapid laboratory diagnosis of influenza, providing monoclonal antibodies specific to H1, H3, H5 and H7, or other, are available, in regions where NAT is not available. Virus Isolation
Growing virus in cell culture is the current gold standard for influenza diagnosis and requires inoculation of the patient specimen into cell culture followed by staining with specific antibodies to detect viral antigen. With the exception of initial inoculation of tube cultures or shell vials with primary specimens, viral culture, including manipulation and
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characterization of the viral agent recovered from cultures, should be conducted in a Containment Level (CL)-3 facility using CL-3 operational practices. Material recovered from all cell cultures may be removed from the CL-3 facility for further analysis once viable virus has been inactivated. During a pandemic, virus isolation together with antigenic and genetic analysis will be used to characterize and monitor the pandemic influenza virus. Culture using Madin Darby Canine Kidney (MDCK) or Primary Monkey Kidney (PMK) cell lines using standard protocols will likely detect potential new pandemic strains. Conventional tube culture may take 4 to 7 days. Rapid shell vial methods may reduce this to 1 to 3 days. The ability of currently used or commercially available monoclonal antibodies to detect a pandemic strain will need to be determined. The most reliable means to identify isolates may be achieved by NAT. Typing and Sub-typing
The Ontario Public Health Laboratories will use rapid typing and sub-typing by molecular methods to detect new pandemic strains. All specimens identified as being of the pandemic strain will be forwarded to the National Microbiology Laboratory, or designated Public Health Laboratory, for confirmation. Rapid Testing
If used and interpreted appropriately, rapid EIA (enzyme immunofluorescent assay) -based, commercially available, point of care (POC) diagnostic tests for influenza can aid in the diagnosis and management of patients who present with signs and symptoms of influenzalike illness, and in the management of potential outbreaks.
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Figure 14.1: Influenza Testing During the First Wave of the Pandemic
Some rapid tests identify both influenza A and influenza B, and can distinguish between them; others can identify either influenza A or influenza B. Sensitivity and specificity may vary for rapid tests depending on specimen type and prevalence. Specimens should be collected as close to the onset of symptoms as possible, and not later than 4 to 5 days after symptom onset. Children often shed virus Chapter #14: Laboratory Services
longer and have higher viral titres, which leads to higher test sensitivity in this population. Median sensitivities of rapid diagnostic tests are generally 70 to 75% when compared to virus culture, and specificities are in the range of 90 to 95%. False-positives are more likely to occur when prevalence is low (i.e., at the beginning and end of the influenza season). 14-10
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False-negatives are more likely to occur when disease prevalence is high (i.e., typically during the peak of influenza season). Commercial rapid antigen tests are not currently recommended for the diagnosis of influenza due to a pandemic influenza strain. Because of the less than optimal performance of POC EIA during periods of low influenza activity, the results of these tests must be interpreted with caution and ideally confirmed by an alternate method, such as DFA, NAT or culture. See the WHO recommendations on the use of rapid testing for influenza diagnosis available at: http://www.who.int/csr/disease/avian_infu enza/guidelines/rapid_testing/en/index.htm l. Serology
The clinical utility of serological tests in the event of a pandemic will be limited. Tests that specifically detect antibodies to the pandemic strain will be required. Traditional haemagglutinin inhibition (HAI) provides type-specific diagnosis by a single high titre or a rise in antibody between acute and convalescent specimens. Laboratory Case Definition
Initial and early samples identified as pandemic influenza should be forwarded to the National Microbiology Laboratory (or designate) for confirmation, so a laboratoryproven case will be any case that is identified as positive for the pandemic strain of influenza by more than one method and/or in which reactivity is confirmed by a second laboratory. Once the pandemic strain is confirmed in a given community or region, confirmation by the National Microbiology Laboratory of subsequent samples may not be necessary.
14.7 Specimen Collection and Handling Guidelines General The ability to detect virus is directly related to the quality of the specimen collected, the speed of transportation to the laboratory, and storage prior to testing. Specimens containing large numbers of virus-infected cells are preferred. Acute and convalescent serum samples may be recommended in some circumstances. The following information should be recorded on the specimen requisition at minimum:
• patient name • date of birth • date of collection • specimen type • name and contact information of requester • symptoms (including date of onset) • travel history • contact with other persons with laboratoryconfirmed influenza
• health card number • outbreak number (if applicable). PILPN recommends use of a standardized requisition titled “Severe Respiratory Illness and Pandemic Influenza Laboratory Sheet” to be found at: http://www.phac-aspc.gc.ca/cpip-pclcpi/. This data sheet allows for the collection of various patient identifiers, as well as information specific to the specimen, the symptoms and epidemiological data. Ensure that the specimen container is appropriately labeled with the patient identifier and that this identifier matches the one on the requisition. Those persons collecting specimens should see
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the Chapter on Infection Prevention and Control and Occupational Health and Safety, also in this document, for information on infection control precautions. Collection Times
Based on information available for seasonal, influenza strains of influenza virus, specimens should be collected as close to the onset of symptoms as possible, preferably within the first 3 days, as viral shedding will be highest at this time and may drop to undetectable levels by 5 days. Children and immunecompromised patients typically shed virus for longer periods, and it may be that specimens can be effectively collected up to 7 to 10 days following the onset of symptoms in these populations. If serology is indicated, an acute phase serum should be collected soon after symptom onset, and not later than 7 days after onset. A convalescent serum specimen can be collected 10 to 14 days (or as late as 21 days) after collection of the acute serum specimen. Specimen Type
The choice of specimen may vary with the type of test being performed – particularly with direct antigen testing. As a general guideline, the usual recommended specimen type for detecting influenza is the nasopharyngeal swab (NPS). Other acceptable specimens include: nasopharyngeal aspirate, nasal swab, throat swab, sputum, bronchoscopically-obtained specimens (e.g. Bronchoalveolar Lavage, BAL), pleural fluid, and lung biopsy and lung tissues. Swabs and transport media intended for bacteriological testing are not suitable for influenza testing. PILPN recommends collecting specimens in duplicate if possible in order to facilitate duplicate testing in cases where novel or pandemic influenza must be confirmed by an alternate laboratory or test. http://www.phac-aspc.gc.ca/cpip-pclcpi/. Although the pandemic influenza strain is not Chapter #14: Laboratory Services
yet known, avian influenza A/H5N1 virus is considered a potential pandemic threat. NPS is currently the recommended specimen type for human influenza testing; however, recent data suggests that the recovery of the avian influenza A/H5N1 virus infecting humans may be improved with the collection of throat swabs and lower respiratory tract specimens (Can Med Assoc J. November 2006; 175: 1371). At this time, the optimal specimen type and the correct timing of specimen collection are unknown for either pandemic or avian influenza infections in humans. As additional information becomes available, and these viruses continue to evolve, more definitive recommendations can be made. The Canadian Pandemic Influenza Plan currently recommends collecting different types of respiratory specimens, including NPS, NP aspirate nasal washings, throat swabs and sputa on multiple different days for the detection of avian influenza virus in humans. There have also been cases of avian influenza A/H5N1 detected from the stool and blood of infected patients so the collection of stool (especially in those who have significant gastrointestinal symptoms) and blood should be considered. For patients with central nervous system (CNS) symptoms, a cerebrospinal fluid (CSF) specimen may be warranted. Preferred specimens Nasopharyngeal Swab
Gently tilt the patient’s head back to about 70º from vertical. Bend the wire swab, while in the sterile package, to give it a slight arc. Insert the thin, flexible swab into the nostril and back into the nasopharynx (i.e., the point approximately midway between the tip of the nose and the earlobe), and leave in place for a few seconds. Then slowly withdraw using a gentle, rotating motion. Use a separate swab for the second nostril. Place the swab(s) in the transport medium and break (or cut) the shaft 14-12
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so it can be contained within the appropriate transport tube with the cap securely closed. Nasopharyngeal Aspirate
Nasopharyngeal secretions are aspirated through a catheter connected to a mucus trap and fitted with a vacuum source. Attach suction catheter to the mucus trap and suction apparatus. Measure the distance from the patient’s nostril to the nasopharynx (half the distance from the nostril to the base of the ear). Hold the tubing at that location, and when inserting the tubing into nasopharynx, do not advance the tube beyond that point. Start suction and pass the tube along the base of one nostril into the nasopharynx. Apply suction to obtain secretions from the nasopharynx. Sample both nostrils with the same suction catheter, without moving fingers from the measured position on the tubing. Rinse the suction catheter by aspirating the viral transport medium (VTM) through the catheter. Other specimens Throat Swab
Swab both tonsils and the posterior pharynx. Place the swab in the appropriate transport medium and break (or cut) the shaft so it can be contained within the appropriate transport tube with the cap securely closed. Nasal Wash
Instruct the patient to sit comfortably with head slightly tilted back. The patient should be instructed to say “K” during the procedure to keep the pharynx “closed”. Apply 1 to 1.5 ml of washing fluid (sterile physiological saline) into the nostril. Instruct patient to lean head forward and collect fluid into specimen container. Repeat with alternate nostrils until 10 to 15 ml of specimen is collected. Dilute wash 1:2 in the appropriate transport medium. Nasal Swab
Insert a dry swab into the nostril, parallel to
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the palate, as far as the anterior end of the nasal turbinate, and leave in place for a few seconds. Then slowly withdraw using a gentle, rotating motion. Specimens can be obtained from each nostril using a single swab. Place the swab tip in the appropriate transport medium and break (or cut) the swab shaft so it can be contained within the appropriate transport tube with the cap securely closed. Serum
Collect blood as per the usual protocol for serum samples (3 to 5 ml of whole blood in a serum tube). Specimen Handling Specimens should be collected and transported in the appropriate viral transport medium and shipped to the laboratory immediately following collection (on ice, if possible). Avoid transportation of specimens using a pneumatic tube. Specimens for the direct detection of viral antigens can be refrigerated prior to processing. If specimens for virus isolation must be stored before shipping, they should be refrigerated immediately. If specimens cannot be processed within 48 to 72 hours, they should be frozen at -70º C. Packaging, shipping and transport of specimens must comply with the requirements of the Transportation of Dangerous Goods Regulations, Transport Canada (http://www.tc.gc.ca/tdg/ menu.htm) and the Dangerous Goods Regulations, International Air Transport Association (http://www.iataonline.com). Additional information on the collection, handling and shipping of specimens for the diagnosis of avian influenza A (H5N1) virus infection can be found at: http://www.who.int/csr/resources/ publications/surveillance/WHOCDS_EPR_ARO_2006_1.pdf. 14-13
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• availability of effective prophylaxis or 14.8 Biocontainment and Biosafety Guidelines for Laboratories Processing Pandemic Influenza General Guidelines Risk assessment governs the level of biosafety and containment required when handling an infectious organism. Performing an adequate risk assessment is difficult in the case of preparing for a pandemic as there are several unknowns. In cases where there is incomplete information, it is prudent to take a conservative approach to specimen manipulation. Thus, the level of biosafety required for the handling and processing of specimens will be assessed and updated as required by the Office of Laboratory Security, Centre for Emergency Preparedness and Response (CEPR), in consultation with the CPHLN (Canadian Public Health Laboratory Network), NML (National Microbiology Laboratory), CDC (Center for Disease Control), and WHO (World Health Organization). Factors which need be considered include:
• pathogenicity of the agent and the infectious dose
therapeutic intervention. Laboratory directors are responsible for ensuring that safe and comprehensive policies are in place. It is incumbent upon all laboratory employees to follow and abide by these policies as it is in the best interest of themselves, their colleagues and their communities. In spite of stringent and safe laboratory practices, the laboratorian must always be alert to the possibility of a laboratory accident. Efforts to minimize accidents and transmission of infection in humans are of the highest priority during an influenza pandemic. Infection Control Practices in the Laboratory Available engineering and administrative controls must be assessed and appropriate measures must be in place before handling potentially infectious specimens. To minimize contact, droplet and air-borne or aerosol transmission of influenza virus when handling patient specimens, laboratorians should adhere to standard or enhanced precautions (when appropriate). Standard Precautions
• consideration of the outcome of exposure
• hand hygiene
• natural route of infection
• PPE when handling blood, body
• other routes of exposure possibly resulting from laboratory manipulations (aerosol, ingestion)
substances, excretions or secretions
• avoid use of sharps • environmental hygiene
• stability of the agent in the environment
• appropriate waste management.
• concentration of the agent
Personal Protective Equipment
• the presence of a suitable host
• masks
• laboratory activity planned (e.g. RT-PCR
• disposable gloves
versus culture)
• protective eyewear • long sleeved, cuffed gown.
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PPE should be worn by all laboratory workers handling specimens from a patient being investigated for pandemic influenza; and they should be removed prior to leaving the designated laboratory area. Droplet and air-borne precautions should be employed for procedures such as growing virus in culture, manipulating cultures or tissues, or manipulating patient specimens (e.g. lung tissue) which may result in the generation of aerosols containing virus. Depending on the available engineering controls, precautions may include the use of N95 respirators and negative pressure rooms if available. Decontamination and Disinfection Influenza virus is inactivated by alcohol and by chlorine. Environmental surfaces should be cleaned with a neutral detergent followed by a disinfectant solution. WHO currently recommends hypochlorite (0.5% chlorine bleach) as the disinfectant of choice for influenza A H5N1 contamination. Hypochlorite disinfectants can be safely applied in molecular laboratories, whereas other disinfectants, such as alcohol, may precipitate nucleic acid preparations leading to increased risk of contamination. Additional information can be found within the WHO Guide for Field Operators at: http://www.who.int/csr/resources/ publications/surveillance/WHOCDS_EPR_ARO_2006_1.pdf. All contaminated liquid and solid wastes must be decontaminated prior to disposal, preferably by autoclaving. Direct Hazards Influenza virus can survive for at least a short time (hours) on surfaces in the laboratory environment. This provides a potential direct means of infection for laboratory workers.
Occupational Health and Safety Tip Box Employers shall develop and implement appropriate measures, procedures and training for the protection of workers in consultation with Joint Health & Safety Committees (JHSC) or Health and Safety Representatives and Infection Prevention and Control resources. Some examples of controls in laboratory settings include: •
biological safety cabinets
•
centrifuge(s) with sealed safety caps
•
non-porous work surfaces
•
hand hygiene and cough etiquette signage
•
IPC housekeeping practices
•
Education and training for workers and supervisors
•
personal protective equipment (based on risk assessment)
For more advice on identifying and implementing controls, see the following web sites: http://www.labour.gov.on.ca; http://www.ricn.on.ca; http://www.osach.on.ca; http://www.whsc.on.ca For more information on Occupational Health and Safety Measures and Infection Prevention and Control in Health Care Settings consult OHPIP Chapter 7.
Indirect Hazards An indirect hazard may exist through secondary reassortment with a human or animal influenza virus, as influenza viruses are known to exchange genes by the process of reassortment. For secondary reassortants to be generated, several events need to occur including: infection of the laboratory worker with wild type virus not of the pandemic strain, a concurrent laboratory or community acquired infection with the pandemic or novel strain, and a reassortment event between the two strains. To reduce the chance of infection with wild-
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type virus, laboratory workers should be vaccinated with current seasonal influenza vaccine. Laboratory employees with a possible work exposure may be asked to refrain from returning to work until the end of the incubation period, providing they remain symptom free. Depending on epidemiological and agricultural circumstances, laboratory personnel potentially exposed to a pandemic or novel strain of virus should also avoid visiting some mammalian (e.g., equine and porcine) and avian facilities until a minimum of 14 days after the possible occupational exposure. It is of note that H5 and H7 strains are reportable to the Office International des Epizooties/World Organization for Animal Health (OIE), http://www.oie.int/eng/oie/en_oie.htm. Such an event would have enormous impact on animal and human health and on the economy and the agricultural industry. Containment Levels (CL) The Public Health Agency of Canada currently uses a classification system based on containment level, which indicates the containment required for handling an organism safely in a laboratory setting. The containment level required for work with a particular agent is based on the manipulations generally associated with laboratory-scale research and clinical procedures (see Table 14.4). Information in this document is based on information currently available. Updated information is available from the Office of Laboratory Security, Public Health Agency of Canada at (phone) 613-957-1779, or (fax) 613941-0596 or http://www.phac-aspc.gc.ca/olsbsl/index.html. Interim biosafety guidelines regarding the handling of clinical specimens associated with novel influenza virus subtypes have been developed by the Center for Chapter #14: Laboratory Services
Emergency and Response and can be found in the laboratory annex of CPIP at: http://www.phac-aspc.gc.ca/cpip-pclcpi/. The MSDS for influenza, as of the writing of this document, is currently under review, but will be found at: http://www.phac-aspc.gc/ca/msdsftss/index.html. Containment Level 1 (CL-1)
This level applies to the basic laboratory handling of agents requiring containment level 1. CL-1 requires no special design features beyond those suitable for a welldesigned and functional laboratory. Biological safety cabinets are not required. Work may be done on an open bench top, and containment is achieved through the use of practices normally employed in a basic microbiology laboratory. Containment Level 2 (CL-2)
This level applies to the laboratory handling of agents requiring containment level 2. The primary exposure hazards associated with organisms requiring CL-2 are through the ingestion, inoculation, and mucous membrane route. Agents requiring CL-2 facilities are not generally transmitted by the airborne route, but care must be taken to avoid the generation of aerosols (aerosols can settle on bench tops and become an ingestion hazard by contamination of the hands) or splashes. Primary containment devices such as biological safety cabinets and centrifuges with sealed rotors or safety cups are to be used, as well as personal protective equipment (gloves, laboratory coats, protective eyewear). Environmental contamination must also be minimized by the use of hand washing sinks and decontamination facilities (autoclaves).
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Containment Level 3 (CL-3)
This level applies to diagnostic, research and clinical laboratories, production facilities, or teaching laboratories handling agents requiring containment level 3. These agents may be transmitted by the airborne route, often have a low infectious dose and can cause serious or life-threatening disease. CL-3 emphasizes additional primary and secondary barriers to minimize the release of infectious organisms into the immediate laboratory and the environment. Additional features to prevent transmission of CL-3 organisms are appropriate respiratory protection, HEPA filtration of exhausted laboratory air, and strictly controlled laboratory access. Containment Level 4 (CL-4)
This is the maximum containment available and is suitable for facilities manipulating agents requiring containment level 4. These agents have the potential for aerosol transmission, often have a low infectious dose, and produce very serious and often fatal disease; there is generally no treatment or vaccine available. This level of containment represents an isolated unit functionally and, when necessary, structurally independent of other areas. CL-4 emphasizes maximum containment of the infectious agent through complete sealing of the facility perimeter with confirmation by pressure decay testing; isolating the researcher from the pathogen by containing the individual in a positive pressure suit (most common) or containing the pathogen in a Class III biological safety cabinet line (rare); and decontaminating air and other effluents produced in the facility. Operational Practices
For the receipt and processing of human clinical specimens and tissues from suspicious human novel or pandemic influenza cases, a CL-2 laboratory is required to safely:
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• perform routine diagnostic testing of serum or blood samples
• manipulate inactivated virus particles or portions of the viral genome
• package specimens for transportation to the appropriate diagnostic laboratory for testing
• perform rapid antigen testing • carry out RT-PCR. For the receipt and processing of human clinical specimens and tissues from suspicious human novel or pandemic influenza cases, a CL-2 laboratory and the use of additional operational practices are required to safely:
• aliquot or dilute specimens • perform diagnostic testing that does not require propagation of virus
• perform nucleic acid extraction on untreated specimens
• prepare smears using heat or chemical fixation. Additional operational practices include:
• wearing protective clothing (e.g., protective solid front gowns, gloves, and N-95 respiratory protection) in accordance with the risk of exposure when handling specimens
• manipulations that may produce aerosols should be carried out in a certified biological safety cabinet
• centrifugation of respiratory and tissue specimens should be carried out in sealed centrifuge cups or rotors, both of which are unloaded in a biological safety cabinet.
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For human clinical specimens from confirmed novel or pandemic influenza cases, a CL-3 laboratory, including the use of respiratory protective equipment, is required to safely:
• perform work or diagnostic tests that involve propagation of viral agents in vitro or in vivo
• recovering viral agents from cell cultures • manipulating or concentrating virus. CL-3 facilities must be certified by Health Canada officials prior to conducting this work. Canada’s single CL-4 facility is located in Winnipeg, Manitoba. Specimen handling and testing of specimens potentially containing a pandemic strain of influenza A should be performed in areas physically isolated from those in which routine inter-pandemic human strains or avian or animal strains are being cultured. Table 14.4: Containment Levels Required for Different Testing Methods Laboratory Method
Containment Level
Virus Isolation/Manipulation
CL-3
Immunofluorescence on direct specimens
CL-2
RT-PCR/NAT
CL-2
Rapid Testing
CL-2
Serology
CL-2
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14.9 Guidelines for Laboratory Based Surveillance Ontario’s ability to identify the entry of pandemic virus into the province, or detect changes in the virus, depends upon laboratory based testing and virologic surveillance. Early and rapid identification of a novel influenza virus in humans will serve to guide and inform public health measures and patient management, such as the implementation of disease control strategies, including the use of vaccines and antivirals. Laboratory surveillance activities will likely evolve throughout the pandemic as a reflection of newly available information (see Table 14.5). Objective The fundamental objective of laboratory-based surveillance is to quickly detect, monitor (for antigenic drift and shift in circulating
influenza strains), and characterize novel or pandemic influenza viruses anywhere in Canada. Once the virus is identified and characterized, vaccine strains can be compared to circulating strains, or new vaccines developed in response to circulating strains. Surveillance for antiviral and antibiotic resistance would be on-going. Special Considerations During the interpandemic period, or as soon as possible, national and provincial protocols should be developed that detail studies (including seroprevalance studies) required both during and following the pandemic period. Anti-microbial susceptibility testing and prevalence studies of microorganisms responsible for infections secondary to influenza must be included in the planning.
Table 14.5: Laboratory Surveillance by Pandemic Period and Phase Objective by Pandemic Period Interpandemic Period: To establish baseline influenza activity and to facilitate early detection of new emergent strains.
Pandemic Phase Phase 1 Phase 1: No new influenza virus subtypes have been detected in humans. and Phase 2: A circulating animal influenza virus subtype poses a substantial risk of human disease.
Surveillance Activities Virus isolates obtained under the following conditions should be sent to the National Microbiology Laboratory (NML) as part of routine surveillance. - All laboratories performing virus isolation are to submit both preseason and early isolates. In addition to these, laboratories are asked to send up to 10% of all seasonal influenza isolates – including 5% during the early season, 5% during the latter part of the season and any unusual isolates, isolates from unusual community clusters or institutional outbreaks, or isolates for which the patient has an epidemiological link to an area of concern – to the NML for virus characterization. The following will be treated as priority specimens by the NML: - Isolates of persons whose influenza illness is related to travel to an area of concern. Isolates that test positive would be sent to NML for strain characterization, including anti-viral sensitivity testing. - Isolates collected during peak activity, usually January, which are representative of the season. - Late season isolates after the bulk of outbreak activity ends. - Isolates of a type or subtype present as a minor component (10% or less) of the year’s epidemic. - Influenza A isolates that cannot be sub-typed. - Isolates from persons receiving antiviral agents or from their contacts should they become ill. - Isolates obtained during in-depth investigations of influenza outbreaks occurring in otherwise healthy, immunized populations. - Isolates from cases of suspected animal-to-human transmission of influenza virus.
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Objective by Pandemic Period
Pandemic Phase
Surveillance Activities
Susceptibility Testing: On early and late isolates as appropriate. Sequencing: On early and late isolates as appropriate. Pandemic Alert Period: To ensure detection and characterization of novel or unusual virus immediately upon introduction into the province of Ontario, including strain identification, drift and/or shift, and anti-viral sensitivity.
Phase 3 Human infection(s) with a new subtype, but no humanto-human spread or spread to a close contact only.
As in the Interpandemic Period, with heightened surveillance as directed by the NML and the Pandemic Influenza Committee (PIC). Testing, typing, sequencing and susceptibility testing of select isolates from newly identified “clusters” of influenza-like illness (ILI), institutional ILI outbreaks, travel-related ILI, or cases/clusters with atypical clinical presentation and an exposure history or history of travel to an area of novel virus activity. Influenza viruses can be rapidly detected and typed using molecular methods. Ontario Public Health Laboratories and some Ontario hospital laboratories can provide this technology with increased capacity over standard methods. The NML is available as an out-ofprovince resource and, in addition to sub-typing, will perform susceptibility testing and sequencing. All isolates identified as being of a novel strain, or any other unusual or non-typable isolates, should be forwarded to the NML for further study and for confirmation. Enhanced surveillance includes: • “ring” surveillance consisting of testing close contacts of those known to be infected with a novel strain and who develop ILI or symptoms of novel virus infection. Isolates from all contacts who test positive for influenza would be sent to NML for strain characterization including anti-viral sensitivity testing. • increased testing, including anti-viral sensitivity testing, especially in those not responding to treatment, or those receiving anti-viral prophylaxis that develop symptoms of influenza-like illness. • sub-typing, sequencing and anti-viral sensitivity testing of a select (1%) proportion of the specimens submitted from patients hospitalized with Influenza A. • sub-typing, sequencing and anti-viral sensitivity testing of those persons presenting with febrile respiratory illness (FRI) and/or unexpected outcomes of severe ILI, and a travel history. Health care providers should be reminded to query travel and test for influenza in patients with FRI. Health care providers should have a high index of suspicion for patients with FRI who have recently traveled or had close contact (i.e., within 1 meter) with travelers to any novel/unusual/pandemic influenza affected area, or resided in or visited an area where mass unexplained die-offs of domestic fowl, ducks or wild birds have occurred. Local public health authorities should be notified for all patients with FRI with a positive travel history or close contact with an ill traveler to an area of concern.
Phase 4 Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.
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Health care providers and Public Health authorities in Ontario are advised to continue increased vigilance for the surveillance, recognition, reporting and prompt investigation of novel influenza. Thus, continue as per Phase 3.
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Objective by Pandemic Period
Pandemic Phase Phase 5
Surveillance Activities As per Phase 4. Heightened surveillance to be continued and consistent with direction provided by PIC and NML.
Larger cluster(s) but humanto-human spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible Pandemic Period:
Phase 6
To assist with the identification of the affected population(s) thereby facilitating identification of high risk groups in order to inform public health actions. To monitor and characterize the virus, including strain identification, drift and/or shift, and anti-viral sensitivity.
Increased and sustained transmission in general population (Several outbreaks in at least one country and spread to other countries)
Postpandemic Period return to Phase 1
Sustainable surveillance activities are maintained. Both human and laboratory resources may be scarce by this period depending upon how widespread the pandemic activity is in Ontario. Molecular testing will be the mainstay of both diagnosis and surveillance. Unusual, novel, or non-typable specimens, or specimens from cases with atypical presentation or illness severity will be forwarded to the NML for further investigation. A certain number of specimens are forwarded to the National Microbiology Laboratory for strain characterization and antiviral resistance monitoring. Heightened surveillance for other viruses, not pandemic influenza, will be initiated towards the end of this phase, and as prevalence of pandemic strain starts to decline.
Return to pre-pandemic activities. Review and analyze pandemic period and activities. Revise pandemic plans as needed.
14.10 Guidelines for Laboratory Personnel
collecting information on routine vaccine uptake by laboratory employees.
Vaccination Status Laboratory employees should be vaccinated against the currently circulating strain of influenza. This vaccine is not expected to provide protection against the novel or pandemic strain, but it will reduce the opportunity for concurrent infections and the possibility of reassortment of the novel strain with a strain already well adapted to humans and capable of human to human transmission. It may also help to discriminate between ILI symptoms as the consequence of infections with the seasonal strain, or as the consequence of infection with a laboratory acquired strain, following occupational exposure. See Chapter 14A: Laboratory Tools for a form to assist with
Prophylaxis Personnel employed in the practice of virus culture and the manipulation of cultured virus should do so using CL-3 containment. Some laboratories may elect to stock antivirals in the event of accidental exposure or to offer prophylaxis to employees engaged in high risk activities in accordance with provincial policy (when established). Laboratory employees potentially exposed or at risk should undergo appropriate medical evaluation.
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Education Laboratory leaders are responsible for ensuring that employees are well informed and continually updated on issues related to pandemic influenza and must develop, in collaboration with their Joint Health and Safety Committees, training guidelines which address the proper handling, processing, testing and shipping of specimens potentially containing pandemic strains of influenza. Employees must be properly trained to handle, process, test and ship specimens potentially containing pandemic strains of influenza. For those employees who will have direct patient contact, please see Preventing Febrile Respiratory Illness which contains recommended infection control practices. Archived Serum Laboratories may choose to collect and store serum on all employees in advance of a pandemic for retrospective analysis. Medical Surveillance Medical surveillance of employees at risk of occupational exposure should help ensure appropriate and timely medical intervention and decrease the opportunity for transmission.
Emergency Preparedness at Home Laboratory personnel are reminded of the importance of planning for family and home. See the following guide for this planning: http://www.health.gov.on.ca/english/ public/program/emu/emerg_prep/ emerg_prep_mn.html
14.11 Next Steps The laboratory sector will continue to:
• refine its pandemic plan • develop stockpiles of equipment and supplies
• develop competency-based HHR/ deployment plans for use during a pandemic
• engage in research in support of pandemic preparedness
• develop plans for efficacious virologic surveillance strategies.
Employees working in laboratories with potentially pandemic, novel, or avian strains should report fever or respiratory symptoms to their supervisors. Employees should be evaluated for possible exposures and the course of illness closely monitored. Employees exposed but not yet sick should remain away from work, until appropriate laboratory investigations have been completed, and return to work only pending results and physical well-being.
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Chapter 14A: Laboratory Tools Contents Laboratories Pandemic Influenza Planning Self-Assessment Tool .....................................................1 Laboratory Activities by Pandemic Period and Sector........................................................................20 Collection of Nasopharyngeal Specimens for Pandemic Influenza ..................................................22 Supply and Equipment Checklist...........................................................................................................23 Seasonal Influenza Vaccination Uptake Rates at Ontario Laboratories............................................25 Pandemic Employee Information Matrix ..............................................................................................27
Ontario Health Plan for an Influenza Pandemic August 2008
Laboratories Pandemic Influenza Planning Self–Assessment Tool
This tool is designed to help all laboratories:
• evaluate their level of pandemic preparedness
• develop a pandemic influenza plan • monitor progress in developing their plan
• identify gaps between already developed business continuity or emergency response plans and a pandemic influenza plan, and to prioritize tasks that need to be completed.
Chapter #14A: Laboratory Tools
How to Use the Tool: Indicate, for each of the tasks, and in the appropriate column, whether the task (if applicable) is complete, in progress, or to whom it should be assigned, and its anticipated completion date. Indicate the priority of the task, which may differ for different organizations based on their priorities, as well as their respective levels of risk tolerance. Once appropriate departments have completed their sections of the tool, the laboratory director and management team should review the results, and assign priorities and due dates for the tasks. The tool can then be used to monitor planning progress.
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Laboratories Pandemic Influenza Planning Self–Assessment Tool Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
The Pandemic Plan Does your Laboratory have a Pandemic Coordinator and/or team in place? Are there a Terms of Reference and a planning document for Pandemic Planning? Are the mandate and objective(s) of planning welldescribed and included in the Plan? Has the individual(s) with authority to approve the Pandemic Plan and Terms of Reference, including revisions, been identified in the Plan? Has membership been determined and are sectors/divisions/positions/disciplines/etc. wellrepresented? Are there requirements for review and revision of the Plan, such as annually, or as new International, National, Provincial and/or Local plans are released? Who is responsible for communication of the Plan to employees & clients? What are the mechanisms for communication currently available? What is needed for an efficient communications response? How will it be communicated? (e.g. web site) How is the Plan and the response going to be cocoordinated? (Who is the Lead? Is there a need for a Laboratory Operations Center through which all communications are directed and released?) Does the plan contain defined Emergency Notification and Activation levels? With which trigger(s) is there Full Notification and Full Activation of the plan?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
With which trigger(s) is there Full Notification and Partial Activation? With which trigger(s) will the Laboratory be put on Stand-by Notification? Have the roles and responsibilities for preparedness and response been outlined with respect to each Pandemic Phase (as per WHO recommendations) in the Plan? If your Plan does specify activities that should occur in each phase of the pandemic, does it then identify the corresponding triggers that would initiate those activities? (This is in addition to reducing the selection of tests that are performed, if applicable. For example, if Pandemic level 5 was declared for Canada, but there were no cases in Ontario, would this trigger activation of any part of your plan?) Have you shared your Pandemic Plan with relevant stakeholders (see below)? Do they have Plans and are you aware of a role for your organization within those plans, if any? Have you surveyed these groups to see what information and services they expect from your Laboratory? •
Labor representatives
•
National Planners
•
Provincial Planners
•
Local Planners
•
Municipal Officials
•
Medical Officer of Health
•
Public Health Laboratories
•
Community Laboratories
•
Emergency Responders
•
Hospitals
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
•
Health Care Workers
•
Military or Security Services
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Have you communicated with your local and provincial laboratories to review and assess your needs and their capacity to meet those needs? Have Human Resources issues been addressed, including training, education, health & safety, sick leave, bereavement leave, compassionate leave, etc.? Have you determined your laboratory's Equipment and Supplies needs? (What needs to be stock-piled, how much, how paid for, how managed, and where will it be stored?) Have you developed plans within your Plan that address Business Continuity? Has your organization shared best practices with other businesses in your communities and/or associations to improve laboratory and community response efforts? For example, another organization may have HR policies that it has developed for its Pandemic Plans that it would be willing to share. Have you incorporated or referenced relevant information from other plans in your Plan? Have you included information on local, provincial, national and international Influenza Testing centers for the users of your plan? Has your organization developed or implemented exercises or drills to test the Plan? Has a gap analysis been performed against the Ontario Health Plan for an Influenza Pandemic (OHPIP), in general, and the OHPIP Laboratory Chapter, in particular? (http://www.health.gov.on.ca/english/providers/prog ram/emu/pan_flu/pan_flu_plan.html) Has a gap analysis been performed against the Canadian Pandemic
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Influenza Plan, and in particular, against its Laboratory Annex? (http://www.phac-aspc.gc.ca/cpip-pclcpi/.) Mutual Aid Agreements To avert confusion in an emergency, has your organization established mutual aid agreements with other laboratories and businesses? Do these agreements: •
Define the type of assistance; for example, types of tests, testing volume, length of time?
•
Identify the chain of command for activating the agreement?
•
Define communications procedures?
Mutual aid agreements can address any number of activities or resources that might be needed in an emergency. For example: •
Human Resources
•
Supplies e.g. disposable PPE, Reagents
•
Autoclave services
•
Compensation for increased testing activities
•
Licensing Issues
Material Transfer Agreements Has your organization put in place MTAs for items required to carry out testing? • For example, cell lines, viral strains, bacterial strains, antibodies Policy Development Has your organization established policies unique to a Pandemic which address:
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Employee compensation and sick leave absences (i.e. non-punitive liberal leave)? Leave of absences for employees not ill but needed at home of care for ill family members? (Non-paid leave?) The use of volunteers? Whether students will be allowed to continue in their clinical or education related placements? When can a previously ill person who is no longer ill return to work? (Will a doctor's note be required?) The potential for occupational exposure of employees to Pandemic Influenza, if any? How to address situations in which the employee may have been exposed, or if employee is ill, or becomes ill, at the worksite (e.g., What will be the infection control response? Will immediate mandatory sick leave be implemented?) A flexible worksite (e.g. telecommuting), flexible work hours (e.g. staggered shifts), shortened work hours, and to whom these policies could be applied. (e.g., Administrative/Managerial staff to work from home, technical or support staff, flexible hours for people with children or ill relatives for whom they must care, etc.) Operational Considerations Has your organization set up authorities, triggers, and procedures for: •
Activating and terminating the Laboratory's response plan
•
Altering business operations
•
Shutting down specimen collection centers (SCC) or Laboratories
•
Reducing the test menu
•
Redirection of specimens to alternate testing sites
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
(internally & externally) If your organization has a Business Recovery Plan, has your organization established linkages between it and your Pandemic Flu plan? If provincial services are curtailed because of higher than usual absenteeism rates, has your organization determined what the impact will be on your organization (e.g. invoice payments, license plate renewals, cleaning services, etc.)? If municipal government or local vendors, such as the companies that handle biohazardous waste, are functioning at only minimal capacity, has your organization determined what the impact will be on its operation? Has your organization identified alternate vendors for critical service activities? Has your organization determined: •
How much overtime it can afford?
•
Which supervisory or management activities can be downloaded?
•
What activities can be delayed without putting patients at risk and what would trigger this activity?
•
What kind of administrative tasks can be postponed, and for how long, or transferred to nonlaboratory staff or volunteers? For example, time sheets and purchasing? What would trigger these activities?
•
What are the services, the core skills and licenses needed to perform the skilled activities? (e.g., Review quality control results? Report patient results?)
Absenteeism rates should be closely monitored for the redeployment of staff. Absenteeism may trigger
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
activities. Does the plan describe how absenteeism rates should be captured, and how these rates should be reported to Pandemic Planning team? Does the plan identify the: •
Key positions in your organization and the minimum staff required to keep your Laboratory operating during the Pandemic Period, which could last several weeks (6-12 week duration)?
•
Alternate test sites within and outside the organization and for what tests or activities?
Has your organization worked with other organizations to identify a list of SCC that must remain open to ensure coverage? Have you agreed on what would trigger this event (e.g., HR issues for one or all of the organizations involved)? Has the role of the SCC been delineated? Will it change in the event of a Pandemic? If yes, how and with what impact? If an organization had to temporarily close down some specimen collection centers and redeploy staff, what would the trigger be for this activity? For example, would this be done strictly based on absenteeism, or would a projected absenteeism trigger this activity? If staff have difficulty obtaining transportation to get to work (e.g. service centers closed, vehicle breakdown and no servicing agents open) or getting to a new work location, would your organization be able or willing to assist? How? Has your organization consulted with its Information Technology (IT) staff to determine the information technology infrastructure needed to support employee telecommuting and remote client access? How long would it take to put information technology infrastructure in place, and what would trigger this activity (e.g. Would you do it now, or wait until there is confirmed human to human transmission in other countries or provinces?)
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Did your organization identify IT staff as key? Does the organization have the ability to operationalize HR policies that will allow people to work from home? Are sufficient computers available to facilitate this if required? When should the organization initiate the setup of the additional VPN access (e.g., Pandemic Level 4 or absenteeism 20% greater than normal or a combination of those things), or should they do so now? For Laboratories with more than one site, has your organization determined if there is a need for a focal Pandemic Laboratory Operation Center? Human Resources Issues Employee Support Since employees are your most valuable asset, has your organization considered supporting staff by providing or arranging for any of the following services: •
cash advances
•
salary continuation
•
grief counseling
•
care packages
•
day care
•
resources on planning for the home and the workplace
Has your organization reviewed the capacity of its employee assistance plan? (Many agencies use the same providers, what is the capacity?) Does your plan include: •
Protocols which deal with increased numbers of grievances, workload complaints, refusal to work?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
•
A list of consultants who could be called if Microbiologists, Clinical Chemists, Pathologists, Scientists, or other key employees are not available?
•
The possibility of bringing back recent retirees or using volunteers, and if so, in what capacity could they be used?
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Does your plan include: •
Identified staff that can be redeployed and their skill sets (secretary, manager, strategic planner)?
•
Sending testing to other internal or external locations where the pandemic has not hit yet?
•
If yes, have the details of that agreement been worked out (e.g., type & volume of tests, length of time)?
Have trigger points been identified which determine when these activities will occur? For example would this be done strictly based on absenteeism, or would a projected absenteeism trigger this activity? (e.g. Level 4.1 has been declared somewhere in Canada) Would Laboratories consider working together if their own resources were exhausted or limited? For example, if all the hematology staff in one location were absent, would another Laboratory be willing to accept the work, considering that all laboratories will have their own HR and other resource shortage issues? What conditions would have to be in place for this to happen? (Assuming a force majeure is in place)? Has the organization determined: •
How many part-time employees would be available for full-time hours or willing to work at another location?
•
How many staff would not be able to show up for work if daycare centers or schools are shut down?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Has your organization implemented any processes in its HR department to deal with staff shortages (e.g. requiring the department to maintain contact information for retirees)? Has your organization : •
Had meetings with Union/Labor representatives to discuss any issues that might arise as a result of redeployment of people (e.g. staff performing other people's job functions
•
Reviewed how Bill 56 - Emergency Management and Civil Protection Act might affect it?
•
Identified any College or licensing issues that might result from the redeployment of staff, (e.g., bring in staff from other provinces, bring in retired MLT's engaged in testing).
•
Identified how the organization will reenergize your staff between pandemic waves? Additional paid time off, grief counseling?
Testing Has your organization : •
Inventoried current laboratory services, including types of tests and number of personnel required to receive, perform and report on these tests?
•
Developed suspended testing guidelines, if applicable, and testing algorithms?
•
Determined when and how guidelines and algorithms would be implemented – for example, if your laboratory is not experiencing high absenteeism rates, but the province has declared Pandemic Phase 5?
•
Developed and planned for scenarios that will change testing patterns and volumes for each location? For example, high absenteeism is being
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
experienced in Toronto Laboratories while Eastern Ontario Laboratories are still operating at normal numbers. •
Linked the type of testing that will be available with each Phase of the Pandemic?
•
Determined when directives for specimen type, collection, transportation and testing will be delivered to clients? What will you be doing with samples that come in that will not be tested?
•
Determined how the lab will phase back the regular testing menu? For example, will the Laboratory wait to see if there is a second wave of influenza before it reinstates the inter-pandemic test menu or will it be depend upon staff availability?
If your organization is licensed to perform Influenza Testing: •
Has the testing method been determined and validated against Pandemic Influenza strains?
•
Does the method implemented ascribe to WHO and National guidelines?
•
Has your organization participated actively in the National Microbiology Proficiency Testing program for the molecular detection of potentially Pandemic strains of Influenza?
•
Has a training program been established to ensure redundancy in the testing capabilities in order to address high volumes with limited human resources?
•
Has your organization considered the use of high throughput instrumentation to facilitate increased test requests, with decreased employee numbers and shorter turnaround times (e.g., automated nucleic acid extractor)?
•
Developed reporting and response guidelines?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Anti Virals and Vaccines Has your organization : •
Developed a policy on the use of Vaccines and AntiVirals?
•
Surveyed all laboratory employees for seasonal vaccine uptake? (See Vaccine Uptake Form)
•
Determined who your front line workers are, as defined in the Ontario Health Provincial Influenza Plan (OHPIP)?
•
Identified either priority employees or priority positions and who will receive prophylaxis antivirals, should they be available?
•
Identified either priority employees or priority positions and who will receive vaccine, should it become available?
•
Developed documentation requirements (e.g., photo identification and proof of employment) for receipt of antivirals or vaccines?
•
Required that proof of vaccination be kept with employee health records?
•
Considered the acquisition and stock-piling of antivirals and vaccine for your Laboratory employees?
Safety Issues Infection Control Program Has your organization developed Standard Operating Procedures (SOP) for Infection Control Precautions covering: •
the use of Personal Protective Equipment (PPE)
•
instructions for visitors (in multiple languages, as required)
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
•
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Infection Control Procedures for Patient Service Centers
Has your organization developed tools such as Employee and Visitor Health Status Forms required for entry into facilities? Does your organization have a heightened awareness campaign ready to roll out that includes plans to disseminate programs and materials covering pandemic fundamentals such as: •
signs & symptoms of influenza
•
modes of transmission
•
the importance of hand washing
•
coughing and sneezing etiquette
•
the discontinuance of hand-shaking
•
the implementation of work-from-home policies and other practices of social-distancing
•
extensive work place and work station cleaning (e.g. each employee responsible for detailed cleaning of personal work space thereby ensuring it is done)
•
avoiding the touching of face and eyes or nose especially without adequate handwashing before and after touching
Or, are you planning on acquiring programs and materials covering pandemic fundamentals from other sources? Has the organization: •
Identified the trigger that would cause it to initiate this campaign (e.g. at a particular Pandemic Phase)?
•
Decided to ensure strict compliance with infection control practices, and if yes, when would this occur?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
•
Determined if additional employees will need to be trained on the Transportation of Dangerous Goods?
•
Decided to institute surveillance for influenza-like symptoms among laboratory personnel once a Pandemic has been declared?
•
Decided to minimize the frequency of face-to-face contact among employees, and between employees and clients or vendors? (For example, minimize meetings and encourage, where possible, staff to work from home.)
•
Conducted a sound Risk Assessment addressing specimens containing, or potentially containing, pandemic influenza virus?
•
Consulted the Office of Laboratory Security for up to date information and measure relevant to Pandemic Influenza at: 613-957-1779 or http://www.phac-aspc.gc.ca/olsbsl/aibioadv_e.html
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Communications Has your organization : •
Identified outside sources for timely and accurate Pandemic information; for example, the WHO, Emergency Management Ontario, the Incident Management system within the Ministry Emergency Management Centre, the MOHLTC, the Public Health Branch, the National Microbiology Laboratory, and the Public Health Laboratory?
•
Maintained an up to date Organizational Chart with current phone numbers and other contact information? Has someone been assigned to update this on a regular basis?
•
Developed or maintained an Emergency fan-out tree with current contact information for home & at work? Do all staff have a current copy?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Has your organization : •
Established an emergency communications plan which includes identification of, and contact information, by both location and function, for: •
Key Laboratory Personnel
•
Backups for key contacts
•
Critical Vendors for Supplies and Services
•
Identified a writer, and an approver of communications to clients and staff?
•
Developed a communiqué to alert clients of the reduction in testing menu and the trigger that will set this in motion?
•
Identified members of a distribution list to receive updates on pandemic scientific information as it becomes available?
•
Put in a process to communicate updates on biosafety guidelines (e.g., PPE requirements)?
•
Put a process in place to ensure that communications are culturally and linguistically appropriate to staff and clients?
•
Developed platforms (e.g. hotlines, dedicated websites) for communicating pandemic status and actions to employees, vendors, suppliers and clients inside and outside the Laboratory?
•
Provided Public Health with the identity and contact information of the person to alert should vaccine become available?
Does your organization : •
Plan to educate and train staff on the management of respiratory specimens and other specimens during an Influenza Pandemic?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
•
Educate staff regarding its Pandemic Plan and relevant HR policies? If yes, at what pandemic phase will this happen?
•
Communicate to staff to whom, how and when the organization will supply prophylaxis and vaccines?
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Equipment & Supply Management Has your organization developed a list of critical vendors for supplies and services? Has your organization enumerated 4 weeks’ supply of the critical items listed in "List of Equipment and Supplies", in addition to other identified items unique to your operation? Which of these are required at what locations within the organization? Does your organization have the storage capacity for this amount of material? If not, has your organization identified triggers which identify at which points additional items listed in "List of Equipment and Supplies" would be ordered? For example, if Pandemic Level 4 has been declared somewhere in Canada, would the Laboratory start to stockpile 4 weeks worth of PPE, or would it do so sooner? Does your organization have a process for distribution of stock within and between sites? Has your organization made arrangements with vendors to sequester reagents, or has it asked if they have the ability to supply your organization with the applicable items of your “List of Equipment and Supplies”? Has it confirmed that, if all the laboratories reacted at the same time – for example in Pandemic Phase 5 – they would still be able to supply you? If not, how long would the wait be for supplies? Has your organization determined when it will begin purchasing to augment stockpiles during the interpandemic period?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Transportation Courier Issues Has your organization communicated with its couriers to review potential issues which might arise during a Pandemic; for example, willingness of courier to transport Pandemic Influenza containing specimens, TDG issues, the courier companies Pandemic Plans, alternate service providers, etc.? Has your organization determined whether, should another health facility’s courier system break down due to absenteeism or other causes, your organization would be willing or able to assist? Legal Issues Are their any liability issues associated with your distribution plan for prophylaxis or vaccines? Has your organization had HR pandemic policies reviewed by your legal department? Are there any constraints to the organization's Plan as a result of the Occupational Health & Safety Act (OHSA)? Are there any constraints to the organization's Plan as a result of the College (various) regulations? Documentation Does your organization have all the information identified in the self-assessment documented in a plan? If not, does the plan contain cross-references to resources where this information is available? Ethical Considerations Has your plan been developed within an Ethical Framework? Did an Ethicist or Team of Ethicists consult on, and review, your plan prior to its publication?
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Activities
Assigned to
Completed
In Progress % completed
Due Date
Not Started
Priority of Activity A: 3 months B: 3-9 months C: 9-16 months D: not applicable
Comment (e.g. already covered in business contingency plan, date last reviewed and approved)
Research & Development Have you identified Research and Development issues related to Pandemic Influenza, which might include, but are not limited to: •
Scientific Research
•
Operations
•
Financial Requirements
•
Modeling Exercises
•
Anticipated Absenteeism Rates
Budget Has your organization developed or established a budget for Pandemic Planning and for implementation of the Plan? Post-Pandemic Activities Has your organization determined when it would take steps to resume normal operations? (Establish a recovery team, if necessary, or establish priorities for resuming operations.) Review and revise your Pandemic Plan.
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Laboratory Activities by Pandemic Period and Sector The following table summarizes the recommended activities for Ontario laboratories by pandemic period and phase. WHO Pandemic/ Phase Interpandemic Period: Phase 1 No new influenza virus subtypes have been detected in humans. An influenza virus subtype may be present in animals, but the risk of human infection is considered low.
Interpandemic Period: Phase 2
Public Health Laboratories
Hospital Laboratories
Community Laboratories
Provide routine testing.
Provide routine testing.
Provide routine testing.
Introduce influenza molecular diagnostic methods to minimum of 4 designated testing sites.
Introduce influenza molecular diagnostic methods to designated testing sites.
Participate in pandemic planning.
Provide appropriate training (including biosafety) and participate in proficiency testing programs.
Provide appropriate training (including biosafety) and participate in proficiency testing programs.
Participate in pandemic planning.
Participate in pandemic planning.
Maintain an up-to-date list of services to be offered or suspended during a pandemic.
Maintain an up-to-date list of services to be offered or suspended during a pandemic.
Continue to participate in laboratory-based surveillance for new subtypes and strains of influenza.
Continue to participate in laboratory based surveillance for new subtypes and strains of influenza. Continue all Phase 1 activities.
Continue all Phase 1 activities.
Continue all Phase 1 activities.
As in Phase 2, with heightened alert and surveillance testing to facilitate early detection of new virus entry into Ontario. Molecular diagnosis and typing at designated sites.
As in Phase 2, with heightened alert and surveillance testing to facilitate early detection of new virus entry into Ontario. Molecular diagnosis and typing at designated sites.
As in Phase 2.
As in Phase 3 with increased laboratory surveillance activities, including typing, sequencing and anti-viral sensitivity testing.
As in Phase 3 with increased laboratory surveillance activities, including typing, sequencing and anti-viral sensitivity testing.
As in Phase 3.
A circulating animal influenza virus subtype poses a substantial risk of human disease. Pandemic Alert Period: Phase 3 Human infection(s) with a new subtype, but no human-tohuman spread or rare instances of spread to a close contact only. Pandemic Alert Period: Phase 4 Small cluster(s) with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans.
Review and update plan as necessary. Confirm technical and biosafety training of all staff is complete. Implement relevant activities of the pandemic plan.
Chapter #14A: Laboratory Tools
Review and update plan as necessary. Confirm technical and biosafety training of all staff is complete. Implement relevant activities of the pandemic plan.
Review and update plan as necessary. Confirm technical and biosafety training of all staff is complete. Review screening protocols for outbreak situations. Implement relevant activities of the pandemic plan.
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WHO Pandemic/ Phase Pandemic Alert Period: Phase 5 Larger cluster(s) but human-tohuman spread still localized, suggesting that the virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible.
Public Health Laboratories
Hospital Laboratories
Provide direction on testing, cell lines, and biosafety guidelines to all testing sites.
Ensure required reagents and protocols in place.
Ensure required reagents and protocols in place.
Implement the pandemic plan.
Community Laboratories Ensure all community sites have up to date information regarding implementation of selective testing and screening protocols and biosafety guidelines. Implement the pandemic plan.
Implement the pandemic plan.
Pandemic Period: Phase 6
Initiate recommended testing methods and biosafety guidelines.
Initiate recommended testing methods and biosafety guidelines.
Initiate selective testing guidelines and appropriate biosafety measures.
Increased and sustained transmission in general population.
Designated PHL sites to perform bulk of influenza testing. Redirect other testing to other surge PHL sites as required.
Designated hospital sites to perform influenza testing.
Several outbreaks in at least one country and spread to other countries.
Deploy plans for suspended testing as required.
Pandemic Period: Phase 6 cont.
Continue Phase 6 activities.
Continue Phase 6 activities.
Continue Phase 6 activities.
Increase virology testing to document decline in pandemic strain and introduction of other respiratory viruses.
Increase virology testing to document decline in pandemic strain and introduction of other respiratory viruses.
Assess laboratory capacity and resources and resume routine testing where possible.
Assess laboratory capacity and resources and resume routine testing where possible.
Assess laboratory capacity and resources and resume routine testing where possible.
Review pandemic period and activities.
Review pandemic period and activities.
Review pandemic period and activities.
Revise pandemic plans.
Revise pandemic plans.
Revise pandemic plans.
Redirect testing to community laboratories as required.
Regional and multi-regional epidemics. Pandemic Period: Phase 6 cont. End of First Pandemic Wave; Pandemic Subsiding. Postpandemic Period return to Phase 1
Chapter #14A: Laboratory Tools
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Collection of Nasopharyngeal Specimens for Pandemic Influenza WASH HANDS BEFORE AND AFTER THIS PROCEDURE WHAT IS THE NASOPHARYNX? The nasopharynx is the upper part of the throat and is located behind the nose. It is the highest part of the pharynx or the throat, which is divided into three parts; the top one being nasopharynx, the middle one being oropharynx, and the last part being the laryngopharynx. Materials 1. Nasopharyngeal swab (with flexible shaft) and rayon tip. 2. Viral transport medium. 3. Personal Protective Equipment (PPE) as required. Personal Protection Risk assessment should be conducted for specimen collection procedures in order to identify associated risks and apply appropriate control measures to reduce the risk of disease transmission. This may involve a combination of administrative controls (safe work practices, procedures) and the use of personal protective equipment (e.g. masks, gloves, gowns) in accordance with the risk or exposure when collecting the specimen. Method
Chapter #14A: Laboratory Tools
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Supply and Equipment Checklist The Equipment and Supplies Checklist is meant to be a first step in identifying supplies and equipment that should be purchased and/or stockpiled, and to monitor the laboratory’s progress in creating those stockpiles. It will also serve to collate the necessary ordering information.
Supplies & Equipment
Normal volume used in 1 week
Estimated Increase per week during Pandemic
Total required for 4 weeks
Cost per unit
Catalogue #
Vendor
Purchased
NA
Infection Control Supplies and PPE Hand Soap Paper Towels Alcohol-based hand rinse Masks * Gloves Gowns Alcohol Wipes Alcohol Surface cleaners and disinfectant Garbage bags Autoclave bags Biohazard boxes & bags Coveralls Boots Face Shields/Eye Protection Safety Goggles Head Covers N95 or N100 Respirators
Chapter #14A: Laboratory Tools
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Supplies & Equipment
Normal volume used in 1 week
Estimated Increase per week during Pandemic
Total required for 4 weeks
Cost per unit
Catalogue #
Vendor
Purchased
NA
Diagnostic Testing Reagents & Supplies Nasopharyngeal Swabs Transport Media Testing reagents, including: DFA reagents RT-PCR or NAAT reagents Cell Culture reagents Supplies related to testing, other than influenza Requisitions Collection Kits Influenza Screening Kits Other Kleenex Toilet Paper Office Supplies
* The Ministry of Health and Long-Term Care is continuing to develop a provincial position on personal protective equipment (i.e., masks). In the absence of a provincial position, references to masks and/or respirators in this document should be interpreted broadly (i.e., facial protection).
Chapter #14A: Laboratory Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Seasonal Influenza Vaccination Uptake Rates at Ontario Laboratories Year of Reporting: 200_ (for 200_/200_ influenza season) Influenza is an acute viral illness characterized by fever, headache, myalgia, prostration, sore throat and cough. Influenza derives its importance from the rapidity with which epidemics evolve, the widespread morbidity, and the seriousness of complications, notably viral and bacterial pneumonias. During seasonal epidemics, severe illness and deaths occur, primarily among the elderly and those with underlying diseases. Clinical attack rates during epidemics range from 10% to 20% in the general community to > 50% in closed populations. The best protection from seasonal influenza is the annual influenza vaccine. The influenza vaccine is available at no charge to anyone aged six months and older living, working or attending school in Ontario. This vaccine is not expected to provide protection against a novel or pandemic strain, but it will reduce the opportunity for dual influenza infections, and hence, the opportunity for reassortment of the novel strain with a strain already well adapted to humans, and capable of human to human transmission. Further, it may help to discriminate between influenza like illness (ILI) symptoms as a consequence of infections with the seasonal strain, or as a consequence of infection with a laboratory acquired strain, following occupational exposure.
Department for future reference. Data collected should reflect vaccination status of staff for the same day of each year for all laboratories. (e.g., November 15, 2006). Definitions Medical Exemption: persons who experienced an anaphylactic reaction to a previous dose or have anaphylactic hypersensitivity to eggs which is manifested as hives, swelling of the mouth and throat, difficulty breathing, hypotension and shock. Applicability: The influenza surveillance protocol is voluntary and applies to all persons who carry on activities in the laboratory including employees, students, volunteers, and contract workers. The protocol does not apply to visitors of the facility. Staff Permanent: Employees assigned permanently to a department(s) in the laboratory. Temporary: Would include temporary employees – for example, from an agency. Would also include assistants/researchers affiliated with a university/other, as the university would hold the contract.
Please keep this form, and records of influenza vaccination for laboratory employees, on file with your Laboratory’s Occupational Health and Safety Chapter #14A: Laboratory Tools
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Laboratory Name: _________________________________ Address: ____________________________________________________ Name of person completing form: __________________________________ Date form completed (mm/dd/yyyy):_____________ Date form submitted (mm/dd/yyyy): _____________ Data for A and B must be provided. If information not known for other categories is not known, please leave blank.
A) Total number of staff* (permanent and temporary) in the facility:
__________
B) Number of vaccinated staff *:
__________
C) Number of unvaccinated staff*:
__________
Of these, the number with documented medical exemption*:
__________
Of these, the number without documented medical exemption*:
__________
D) Number of staff with vaccination status unknown:
__________
Staff Vaccination Rate = (B/A x 100):
__________
Chapter #14A: Laboratory Tools
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Pandemic Employee Information Matrix As part of pandemic planning, it is assumed that there will be a critical shortage of available staff. In order to be able to respond quickly to staff shortages and permit contingency staff planning, this matrix has been developed to collect essential information about qualifications and availability of the workforce. This information will not be used for day-to-day operations. It will only be used in the event of pandemic outbreak or other declared emergency. All employee information will be treated in a confidential manner and only designated staff will have access to the redeployment database. This information is to be updated and copied to the Head of HR on semiannual basis. Department:
Functional Lead:
Alternate/ designate
Contact #
Contact #
Information was last updated as of: yyyy/mm/dd Employee Name (last name, first name)
Employee #
Home Address
Contact Number(s)
Current Workplace Location(s) Also indicate whether you are employed with another organization which may need you during a pandemic
Chapter #14A: Laboratory Tools
Current Mode of Transportation to Work e.g. own vehicle, public transport, car pool, walk
Key Department Activities
Skills (e.g., data entry, driver’s license, First Aid/CPR, languages other than English) For languages other than English, indicate which of the following ability levels: read, write, speak
Indicate License to Practice e.g. MLT, RN, MD & current or lapsed If MLT indicate subject or general
Available To Alter Work Hours Or Work Location (If yes, specify hours and locations including working from home, if applicable, and how much notice would be required for this change)
Indicate equipment currently available at home which might help you perform your job at home (e.g., computer, internet access, cell phone)
Indicate how much overtime you would be willing to work per week
Indicate willingness to be placed on callback list if retiring in next 6 months
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15. Emergency Medical Services There were too few ambulances to carry the sick to the hospital, so mules pulled ambulance carts until the mules, exhausted, stopped working. The Great Influenza, John M. Barry
Based on an attack rate of 35%, Ontario is estimating about 61,254 hospitalizations over a six to eight week period and 2.3 million visits to a flu assessment centre or other outpatient setting. Under the Ambulance Act, municipalities and designated delivery agents are responsible for providing land ambulance services within their jurisdiction. During an influenza pandemic, Emergency Medical Services (EMS) will be responsible for providing land ambulance services in their jurisdiction, including the medically necessary transport of influenza patients.
Centre (PTAC) for all inter-facility patient transfers
•
work with the medical officer of health to develop plans/protocols specific to transferring patients who meet the Ambulance Act criteria for ambulance transport to and from designated non-hospital flu centres
•
assist the medical officer of health in developing plans for alternate means of transportation for patients who do not meet the Ambulance Act criteria for transport by ambulance
•
incorporate non-hospital flu centres into plans so Ambulance Communications Services can dispatch ambulances to those nonhospital destinations
•
identify possible transfer issues that may arise during an influenza pandemic
•
test and evaluate any contingency plans.
15.1 Objectives • To provide guidance for municipalities and designated delivery agents in planning for emergency medical services during an influenza pandemic.
15.2 Planning Municipalities and designated delivery agents need to review their emergency and business continuity plans to ensure they are adequate in the event of an influenza pandemic (see Chapter 15A: EMS Pandemic Preparedness Checklist). Municipal and designated delivery agent EMS services need to:
•
be part of pandemic planning through their local public health unit
•
work with local and regional health facilities to ensure consistent use of the Provincial Transfer Authorization
Chapter #15: Emergency Services
15.3 Continuity of Operations/Surge Capacity Emergency Medical Services have extensive contingency plans in place, including:
•
tiered response agreements with other emergency services (e.g., firefighters, police) to assist with response to emergencies if there will be a delay in the ability of an ambulance to respond 15-1
Ontario Health Plan for an Influenza Pandemic August 2008
•
regulations (in the Highway Traffic Act) that allow EMS to use other emergency responders (e.g., police, firefighters) as drivers
•
staffing/human resource plans to enable services to continue to operate 24/7 in the event of human resource shortages
•
mutual aid agreements with ambulance services in neighbouring communities/regions
•
processes under the Agreement on Internal Trade to certify paramedics trained outside Ontario.
To prepare for a pandemic, EMS agencies are encouraged to:
•
adapt tiered response agreements to include a plan to respond to an influenza pandemic
•
establish a protocol for triaging patients with symptoms of influenzalike illness that will help reduce the pressure on EMS
•
identify non-critical services that could be scaled back or eliminated in a declared pandemic emergency
•
ensure contingency staffing/human resources plans address the possibility of 20% or more of the EHS workforce being unable to work
•
ensure mutual aid agreements and memorandums of understanding are up to date and appropriate for use during an influenza pandemic.
15.4 Supplies and Equipment Like other parts of the health care system, Emergency Medical Services are expected to maintain a four-week supply of equipment and supplies, and the Ministry of Health and Long-Term Care will Chapter #15: Emergency Services
maintain an additional four-week supply of basic personal protective equipment (to cover the first wave of a pandemic). EMS are also expected to work with their suppliers to ensure an ongoing source of supplies and equipment during a pandemic. See Chapter 10A for a supplies and equipment template specific to EMS.
15.5 Infection Prevention and Control/Occupational Health and Safety Because of the nature of their work (i.e., responding to patients with unknown diagnoses), paramedics already maintain a high level of infection prevention and control (e.g., use of N95 respirators) to protect themselves and the people they transport from exposure to infectious diseases. All staff should receive ongoing education in infection prevention and control. For guidelines on infection control, see: Infection, Prevention and Control Best Practices Manual for Land Ambulance Paramedics Vol. 1.0; and Chapter 7 of OHPIP. As part of their planning, EMS agencies may consider implementing certain engineering controls and administrative practices to reduce the potential spread of influenza in offices, administrative centres and the field, such as:
•
promoting annual influenza immunization
•
establishing hand sanitizer stations at entrances to stations and other system facilities (e.g., dispatch/supply centres)
•
screening staff for symptoms of influenza-like illness 15-2
Ontario Health Plan for an Influenza Pandemic August 2008
•
reviewing cleaning/disinfection protocols
•
restricting visitors
•
during a pandemic, holding meetings via teleconference or cancelling meetings or training activities.
Occupational Health and Safety
•
stress and anxiety.
For more information on psychosocial support for workers, see Chapter 21. During the SARS outbreaks in Toronto, paramedics reported that the most difficult part of their work was dealing with the “unknown”. EMS should work closely with hospitals, nursing homes and other settings to establish open, effective communication systems.
Tip Box Employers have developed and implemented appropriate measures, procedures and training for the protection of workers in consultation with Joint Health & Safety Committees (JHSC) or Health and Safety Representatives and Infection Prevention and Control resources. See measures in Chapter 7 for more information. Some examples of controls for emergency medical services include: surgical mask on patient in transport (as appropriate) hand hygiene and cough etiquette practices appropriate IPC housekeeping practices by trained workers education and training for workers and supervisors personal protective equipment (based on risk assessment) Web resources: http://www.labour.gov.on.ca; http://www.ricn.on.ca; http://www.osach.on.ca; http://www.whsc.on.ca For more information on Occupational Health and Safety Measures and Infection Prevention and Control in Health Care Settings consult the OHPIP Chapter 7.
15.6 The Role of First Responders in Surveillance The EHS system can play a vital role in surveillance and contact tracing – particularly when all requests for interfacility transfers are submitted through the Provincial Transfer Authorization Centre (PTAC). First responders are often the first to notice an outbreak pattern (e.g., large number of requests for transfers from a particular nursing home, which may go to different hospitals). When all inter-facility transfers are made through PTAC, the system can trace all patients who may have been exposed in the health care setting. This was the case during the SARS outbreak in Toronto. PTAC helped facilities quickly identify people who had been exposed so they could be isolated.
Psychosocial Support for Workers
15.7 Air Ambulance Services
During an influenza pandemic, EMS staff are likely to be working extended or extra shifts. EMS should have in place strategies to help staff cope with:
Ornge, a non-profit organization, was appointed in July 2005 by the Ontario Ministry of Health and Long-Term Care to coordinate all aspects of Ontario’s air ambulance system.
•
responder fatigue
•
the discomfort of wearing personal protective equipment for long periods of time
Chapter #15: Emergency Services
Education Ornge has an infection control manual that sets out appropriate precautions for preventing illness in Ornge staff. When 15-3
Ontario Health Plan for an Influenza Pandemic August 2008
the World Health Organization declares a pandemic, the manual will be updated to reflect the epidemiology of the novel virus and Ornge will implement a focused education plan to ensure all staff are aware of appropriate infectious control procedures. The manual and education plan will be reviewed and updated on an on-going basis as scientific information about the novel virus evolves.
urgent transports on dedicated critical care aircraft are deferred.
•
deferring staff holidays until the pandemic wave is over
•
altering current crew configurations as required from two Critical Care Paramedics to one Critical Care Paramedic and one Acute Care Paramedic; and from one Critical Care Paramedic and one Acute Care Paramedic to one Acute Care Paramedic and one Primary Care Paramedic to maximize existing resources.
Triage Triage decisions about the most effective use of air ambulance services during a pandemic will depend on the patient’s probability of survival, the availability of resources, and the needs of other patients who also require our services. Ornge will utilize the Critical Care Triage Criteria outlined in OHPIP (Chapter 17) when triaging critically ill patients for transport. Optimizing Ornge Capacity Ornge will need to find novel ways to optimize its ability to maintain services during a pandemic including:
•
•
•
Equipment To prepare to function during a pandemic, Ornge will need to stockpile appropriate personal protective equipment (PPE) for all staff who have direct contact with patients, including paramedics, nurses, and pilots. A four-week stockpile of PPE will be required, and quantities will be calculated by predicted call volumes for each base. The PPE required will include:
•
N95 respirators
deferring services for non-life threatening conditions where no severe adverse health consequences are anticipated from the delay or cancellation of services (e.g., primary care non-urgent transports). These services, including the length of time they can be deferred, will be identified as part of pre-pandemic planning
•
gowns
•
gloves
•
goggles.
ensuring that contractual providers have a pandemic/business continuity plan in place
15.8 Next Steps
developing a plan to re-deploy Ornge staff, including PCP staff who will be freed up when primary care non-
Chapter #15: Emergency Services
Supply chains will be organized now to ensure Ornge can access enough supplies at the outset of a pandemic to adequately protect staff past the initial 56-day stockpile if required.
EHS will:
•
develop more detailed plans to provide psychosocial support for workers
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•
develop guidelines for resuscitating patients with influenza
•
develop guidelines for transporting people who have died from influenza
•
work with hospitals, nursing homes and other settings to establish
Chapter #15: Emergency Services
effective communications about patients being transported and enhance transfer services
•
explore alternate/expanded roles for paramedics.
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15A. Emergency Medical Services Tools
Contents Pandemic Planning Checklist for Emergency Medical Services (EMS) ..............................................1
Ontario Health Plan for an Influenza Pandemic August 2008
Pandemic Preparedness Checklist for EMS Task/Activity
Yes/No
Action Required
1. Planning 1.1
Has your Business Continuity plan been reviewed to ensure it can be implemented using pandemic flu assumptions? • 35% attack rate over the duration of the pandemic • Peak employee absenteeism rate of 20-25%
1.2 Has your EMS agency developed plans to address any issues unique to pandemic influenza? 1.3 Is your EMS agency involved in developing local pandemic plans?
2. Training/Education 2.1. Does the EMS agency have a designated certified Occupational Health and Safety Committee member and backup, who are known to staff and available 24/7? 2.2 Does the EMS agency include pandemic education material in staff orientations? 2.3 Are all staff aware of their roles/responsibilities during a pandemic outbreak? 2.4 Is there a designated area where staff can obtain information and be alerted to a potential influenza pandemic? 2.5 Does the EMS agency provide ongoing pandemic training and education? 2.6 Does the EMS agency have policies and procedures to quickly train staff for new or altered roles?
3. Supply Chains 3.1 Has the EMS agency identified the supplies required during an influenza pandemic? (See Chapter 10 for supplies template) 3.2 Will suppliers be able to fulfill contracts during an influenza pandemic (i.e., do they have a pandemic plan)? 3.3 Will suppliers be able to fulfill contracts if the border with the USA closes? 3.4 Does EMS agency have a backup source of supply if current vendors are unable to deliver?
4. Human Resources 4.1 Has the EMS contingency staffing plan been reviewed to ensure it will be adequate during a pandemic? 4.2 Does the EMS agency have a policy for addressing work refusal? 4.3 Does the EMS agency have plans to support staff during a pandemic?
5. Communications 5.1 Has the EMS agency established a communication system with the local public health unit and other partners?
Chapter #15A: Emergency Medical Services Tools
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5.2 Does the EMS agency have a plan for communicating with staff, volunteers and family members during a pandemic, including the person/s responsible for notifying staff and families?
7. Infection Control/Occupational Health and Safety 7.1 Has the EMS agency implemented engineering controls and administrative practices that will reduce the potential for the spread of influenza? 7.2 Does the EMS agency have a process in place to implement routine assessment of staff for febrile respiratory infection (FRI) and/or influenza-like illness (ILI) when applicable? 7.3 Has the EMS agency developed plans to provide support for staff during a pandemic?
Chapter #15A: Emergency Medical Services Tools
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16. Community Health Services For purposes of OHPIP, community health services include:
• community care access centres, home care providers, and community support services
• community mental health and addiction services
• other community-based health services. The 2008 edition of OHPIP includes the plan for community mental health and addiction services. Plans for home care services and other community-based health services are still under development. For primary care services, see Chapter 11; for long-term care services, see Chapter 19.
Chapter #16: Community Health Services
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16.1 Community-based Mental Health and Addiction Services [The pandemic] kept people apart … It took away all your community life, you had no community life, you had no school life, you had no church life, you had nothing … It completely destroyed all family and community life. People were afraid to kiss one another, people were afraid to eat with one another, they were afraid to have anything that made contact because that’s how you got the flu …There was an aura of constant fear that you lived through from getting up in the morning to going to bed at night. The Great Influenza, John M. Barry
An influenza pandemic will threaten the health of people with mental health and/or addiction problems. It will also disrupt the services they rely on to manage their health. During a pandemic, the primary responsibilities of agencies and organizations that provide communitybased mental health and addiction services will be to:
• help clients access the mental health, addiction and other essential health and social services they need
• support as many clients as possible in the community to reduce the need for hospitalization and free up more beds for influenza care
• educate clients about how to reduce the risk of acquiring influenza and where to go for care
who develop influenza but do not require hospitalization. This chapter is designed to provide a framework that community-based mental health and addiction agencies can use to prepare for an influenza pandemic.
16.1.1 Objectives • To help community-based mental health and addiction services prepare for an influenza pandemic.
• To maintain essential communitybased mental health and addiction services during a pandemic.
• To make effective use of mental health knowledge, skills and services during a pandemic.
• To slow the spread of influenza within community-based mental health and addiction service settings.
• help clients with flu symptoms connect with flu centres and get the care they need
• slow the spread of influenza in their settings. In addition, community-based agencies and organizations that provide residential programs and services – such as supportive housing programs, group homes, Homes for Special Care and residential treatment programs – will need to provide some direct care for residents
Chapter 16: Community Health Services
16.1.2 Implications of an Influenza Pandemic For People with Mental Health and/or Addiction Problems Increased Vulnerability
Many clients with severe mental illness will be vulnerable to influenza because their health may already be compromised. Many clients live in congregate living settings (e.g., homeless, shelters,
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supportive housing, Homes for Special Care) where – because of space restrictions, crowding and the overall health of the population – the risk of being exposed to influenza will be higher. Some clients may find it difficult to comply with public health measures designed to slow the spread of influenza (e.g., voluntary isolation, social distancing, cough etiquette). Any disruption in the supply of alcohol or illegal drugs could lead to an increase in crime and demands on law enforcement and/or push people with addictions into withdrawal, and increase the demand for treatment services. Clients in residential programs may have less interaction with family and friends, which could affect their mental wellbeing. Problems Accessing Services
Hospitals providing care for influenza patients may restrict access to mental health outpatient clinics and detox or withdrawal programs. These restrictions occurred during the SARS outbreaks and made it very difficult for clients with mental health and addiction problems to get the treatment (including medications) they needed. Hospitals providing care for influenza patients may discharge mental health patients to the community, increasing the demands on community services. They may also be hard-pressed to meet the demand for outpatient services, including services that are essential for other parts of the health care system, such as psychogeriatric outreach to long-term care homes.
Chapter 16: Community Health Services
For Agencies and Organizations Providing Mental Health and Addiction Services Increased Demand for Services
Community-based agencies will be under pressure to provide as much care as possible for people with severe mental illness, reducing the need for hospitalization. They may also be asked to assist in providing outpatient services. Many people with mental health and addiction problems do not have a primary care provider, and may turn to community-based mental and addiction agencies for care and advice on influenza. Residential and group living settings, such as group homes, supportive housing units, Homes for Special Care and residential addiction treatment programs, provide housing services and can anticipate having clients with influenza who are not sick enough to require hospitalization. Staff in these settings may need to provide a basic level of medical care, but may not have appropriate knowledge or skills. Community-based programs that provide both mental health and primary care services may see an increased demand for primary care, assessment and influenzarelated treatment services. Workforce Disruption
At the peak of the pandemic, as many as 20 to 25% of the mental health and addictions workforce may be unavailable – due to illness, family responsibilities or other demands in the health care system. Depending on their competencies, some mental health professionals – particularly doctors, nurses and counsellors – may be asked to provide influenza-related services (e.g., provide counselling for health professionals dealing with stress),
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and may not be available to provide community-based mental health and addiction services. Agencies and organizations that provide communitybased services may have to rely on other types of providers and volunteers to maintain their programs. Need for New Knowledge and Skills
Mental health and addiction settings are not necessarily knowledgeable about infection prevention and control, and may not have the systems, policies and equipment to slow the spread of influenza in their congregate living facilities or office-based programs. Staff in congregate living settings may not have the skills to provide basic care for residents with influenza. To be prepared, community-based mental health and addiction agencies should develop plans to maintain essential services during a pandemic.
16.1.3 Planning Review and Update Emergency Plans Every community-based mental health and addiction agency should develop a plan for an influenza pandemic, which should be reviewed and updated annually or more frequently if required. These plans should be based on the business continuity and emergency plans already in place in mental health and addiction agencies, modified to reflect the potential severity of an influenza pandemic. (See Chapter 16A for a planning checklist.) Coordinate Planning with Other Health Organizations Because an influenza pandemic will affect the whole community, mental health and addiction services cannot plan in isolation. They should:
• connect with the local public health unit, which is responsible for Chapter 16: Community Health Services
coordinating local pandemic health plans
• work with other health organizations in the community, including other mental health and addiction agencies, hospitals, community care access centres (CCACs), home care providers, primary care providers, emergency medical services, local public health units, pharmacies, social services and police services, to plan for the needs of people with mental health and addiction problems during a pandemic. For example, flu assessment centres will need staff with the skills to manage disadvantaged populations (i.e., people with mental health or addiction problems, people who are homeless)
• familiarize themselves with other organizations’ plans and functions during a pandemic
• identify possible scenarios and how they would be handled by the system (e.g., if the hospital has to discharge psychiatric patients, how will the community provide care? If hospitals limit access to out-patient services, who will dispense medications and how will clients access their medications or be monitored for side effects? If hospital-based outpatient programs are no longer able to provide psychogeriatric services for long-term care homes, how will the mental health needs of the homes be met? If the community experiences a large number of influenza cases and deaths, how will the system provide counselling and psychological support? How will the community meet the needs of highly vulnerable people, such as people who are homeless or street-involved? Given that 40 to 50% of people who use
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shelters have mental health problems, how will the community ensure that shelters or other emergency services continue to operate throughout a pandemic?)
• identify opportunities to collaborate/ share resources during a pandemic. For example, mental health drop-in centres or withdrawal management centres (particularly those not on a hospital site) could be used to deliver some influenza-related services or to provide services for vulnerable populations, such as people who are street-involved or Aboriginal peoples living off-reserve
• collaborate/consult with hospitals about any plans the hospitals are developing to curtail or change mental health services managed by hospitals (e.g., withdrawal management services, outpatient programs) to ensure that decisions do not have unintended negative consequences (e.g., increasing the number of people seeking mental health services in hospital emergency departments).
• work with partners, such as acute care hospitals and community psychiatrists, to develop criteria for mental health and addictions clients who will be admitted/maintained in hospital and those who will be cared for in the community
• work with partners to develop criteria and procedures for managing clients in congregate living settings who develop influenza (e.g., who will provide care? when should they be transferred to another setting?)
• work with police to plan how to manage safe beds and provide mobile crisis services during a pandemic
Chapter 16: Community Health Services
• determine whether community-based mental health and addictions staff will be asked to work in other parts of the system during a pandemic and/or whether some hospital staff currently working in mental health will be available to work in the community (e.g., mental health nurses, psychiatrists)
• identify services that may be in greater demand during a pandemic (e.g., counselling and support to address pandemic-related fear, anxiety, refusal to work, non-compliance with public health measures, grief and loss; practical support), and how they will be delivered
• help shape public messages to reduce fear and reinforce coping mechanisms.
16.1.4 Assess Clients’ Needs Community-based mental health and addiction services should assess clients’ care needs in order to identify:
• clients whose mental health and addiction services must be maintained at all times (e.g., clients who require safe beds, clients being served by ACT teams, clients on methadone)
• clients who require acute care services and those whose needs can be met in the community
• clients whose needs can be met in nontraditional ways (e.g., counselling by phone)
• clients who will need assistance with practical needs, such as food and transportation
• clients who will need assistance obtaining medication and/or adhering to antiviral therapy if they fall ill with influenza
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• clients whose needs can be met by family members with some support from professionals – including clients in congregate living settings who could be discharged home
• clients whose care can be safely delayed or deferred
• clients at highest risk of complications from influenza. The assessment should include plans to limit their risk of exposure. Agencies should keep client assessments up-to-date based on the criteria listed below. Identify Services that must be Maintained and Services that Could Be Curtailed During a pandemic, community-based mental health and addiction services will likely be short staffed, and will need to use limited resources to deliver essential services. Agencies will identify:
• services that MUST be maintained • services that could be reduced or curtailed (e.g., offered once every two weeks instead of once a week), or delivered in different ways (e.g., smaller groups, by phone instead of in person). The criteria to determine services to be maintained would include:
• the service is required to prevent/ reduce danger to self or others
• lack of or delay in treatment will have a serious negative impact on client’s health
• the ability of the service to reduce
• increased need for the service during a pandemic. Table 16.1.1 suggests the types of mental health and addiction services that should be maintained and those that could be curtailed or adapted. Note: the need to reduce or curtail services will depend on the severity of the pandemic. If the pandemic strain is mild (i.e., <.5% of deaths in population), agencies may be able to maintain almost all services; if the pandemic is severe (i.e., >2% of deaths in population), it will be much more difficult to maintain services, and many will have to be reduced or stopped. For more discussion of pandemic severity, see Chapter 6. Storage and Tracking Systems for Antivirals With the exception of ACT teams and some residential programs, it is not likely that community-based mental health and addiction agencies will be storing or distributing antivirals for treatment; however, if it is appropriate or necessary for them to do so, they will be given instructions by the local public health unit.
16.1.5 Infection Prevention and Control/Occupational Health and Safety To slow the spread of influenza in community-based mental health and addiction settings, agencies should comply with the Occupational Health and Safety Act, and adopt the hierarchy of controls approach (see Chapter 7). The type and level of controls will vary depending on the nature of the setting and type of services being provided.
demands on other parts of the health care system
• the ability of the service to slow the spread of influenza
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Table 16.1.1 Maintaining Mental Health and Addiction Services Program/Service
Maintain or Increase
Reduce or Delay
Acute in-patient services
Maintain as long as possible; if it is necessary to move patients out of hospitals, identify other ways to deliver services (e.g., community-based mental health agencies or services, home care, by phone, in other residential settings)
Hospital-based psychiatric programs (e.g., eating disorders)
Maintain but provide services at another site or in other ways (e.g., by phone)
Forensic services and safe beds
Maintain
Assertive Community Treatment (ACT) Teams, case management programs, and other services for severe mental illness
Maintain or increase depending on the capacity of hospitals to provide in-patient care
Outreach, including crisis services, peer programs and psychogeriatric outreach to long-term care homes
Maintain services as long as possible
Drop-in centres, including peer programs
Maintain services as long as possible
Supportive housing, and other residential MH services
Maintain
Access to stabilizing medication, including methadone, and other harm reduction supplies (e.g., needle exchange programs)
Maintain or increase to compensate for any disruptions in supply from other usual sources (e.g., hospital or community pharmacies)
Outpatient mental health or addiction counselling services
Maintain but provide services in different ways (e.g., less frequently, by phone)
Postpone admission of new clients on a case-by-case basis; identify other ways to deliver services
Residential addiction treatment services – including withdrawal management services
Maintain existing clients through course of treatment Consolidate services on fewer sites to compensate for staff shortages
Postpone admission of new clients on a case-by-case basis or identify other ways to deliver services Reduce group size
Non-residential mental health or addiction services, including peer programs, employment supports/ alternative businesses, day treatment programs, and community withdrawal management programs
Maintain existing clients through course of treatment, provide services in other ways (e.g., by phone, Internet)
Postpone on a case-by-case basis for new clients
Postpone admission of new clients on a case by case basis; identify other ways to provide support
When providing face-to-face service, screen clients for flu symptoms and take appropriate steps (e.g., referring clients to a flu centre, social distancing, and taking other precautions) Screen clients for flu symptoms and take appropriate steps (e.g., referring clients to a flu centre, social distancing, and taking other precautions) Adapt functions to implement social distancing strategies to prevent spread of flu in setting (e.g., limiting number of people in a given space, providing some services outside, bag meals)
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Postpone admission of new clients on a case-by-case basis
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Environmental Controls: Changes to the Physical Environment Agencies and organizations should make every effort to create physical environments that will reduce the spread of influenza, and protect staff, clients and visitors (e.g., hand sanitizer stations at the doors, plexiglass barriers between receptionists and clients, enough space in waiting areas that clients can stay about two metres from one another, an entrance designated for people with flu symptoms). Note: OHPIP recommends the use of alcoholbased hand sanitizer. Some community-based mental health and addiction agencies may be concerned about the use of alcohol-based sanitizers in environments where many clients smoke (i.e., because alcohol-based sanitizer is flammable) or have addictions to alcohol. In those cases, agencies should explore alternatives to alcohol-based sanitizers with their local public health unit or develop additional safety procedures for how alcoholbased sanitizer is distributed (e.g., controlled by staff). Administrative and Work Practices: Changing the Way Agencies Work Community-based mental health and addiction agencies should establish policies and practices to reduce the spread of influenza, including:
• an immunization policy, encouraging all staff, clients and volunteers to have the annual flu shot (Note: this will not reduce the individual’s chance of getting the pandemic flu virus but does help keep the person in good general health.)
• hand hygiene policies and procedures, and cough etiquette
• strategies to help staff, clients, volunteers and visitors comply with
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hand hygiene and other protective measures Screening, Surveillance and Care in Residential and Group Living Settings During a pandemic, agencies operating residential programs should monitor clients for symptoms of influenza-like illness. Clients with symptoms should be taken/referred to a Flu Centre to be assessed. and referred to the appropriate level of care. Depending on the attack rate and severity of the pandemic, people with influenza are only likely to hospitalized if their illness is life-threatening (i.e., requires intensive care). Otherwise, they will be cared for where they live. For assistance with infection control procedures, residential settings should contact their Regional Infection Control Network, local public health unit or the infection control department at the local hospital or long-term care home.
• a screening/surveillance procedure to assess staff, clients, volunteers and visitors for flu symptoms, and implement appropriate precautions (e.g., asking clients with flu symptoms to sit in a separate waiting area or wear a surgical mask) •
encouraging staff, volunteers and visitors to stay home when ill
•
social distancing procedures to be followed by staff in congregate living settings, such as sitting people about two metres apart at meals, organizing two seating times for meals, cancelling social activities, feeding people who have the flu in their rooms, cohorting people with flu in the same room, grouping residents with flu symptoms in one part of the facility; asking residents with influenza-like illness to wear a surgical mask. Note: droplets from a coughing or sneezing person can be expelled a distance and may be inhaled by someone who is within two metres of the coughing or sneezing person.
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•
cleaning more frequently and following environmental guidelines for cleaning (see Chapter 7)
•
delivering certain services by phone or Internet, or in smaller groups.
Occupational Health and Safety Tip Box Employers have developed and implemented appropriate measures, procedures and training for the protection of workers in consultation with Joint Health & Safety Committees (JHSC) or Health and Safety Representatives and Infection Prevention and Control resources. See measures in Chapter 7 for more information. Some examples of controls community health services include: hand hygiene and cough etiquette signage appropriate IPC housekeeping practices hand hygiene education and training for workers and supervisors
Community-based agencies that are providing some level of care for clients with influenza (e.g., residential programs) or outreach to vulnerable populations may require a higher level of personal protective equipment. See Chapter 7. To determine which workers need access to personal protective equipment and the type of equipment they require, agencies should conduct a risk assessment (see Chapter 7). Staff Training and Education Staff should have appropriate training and education in infection prevention and control techniques – particularly staff working in congregate living programs. Education programs should be developed in consultation with the Joint Health and Safety Committee or representatives, and should include:
personal protective equipment (based on risk assessment)
• the agency’s influenza pandemic plan
Web resources: http://www.labour.gov.on.ca; http://www.ricn.on.ca; http://www.osach.on.ca; http://www.whsc.on.ca
• any procedures or programs that will
For more information on Occupational Health and Safety Measures and Infection Prevention and Control in Health Care Settings consult the OHPIP Chapter 7.
Personal Protective Equipment Community-based agencies that are NOT providing direct care for clients who have influenza or working closely with vulnerable populations (i.e., homeless clients, people with severe mental illness who might have to be restrained) will require only basic personal protective equipment, such as a supply of surgical masks and hand sanitizer. Masks would be worn only when staff have to be within three feet of a client who has flu symptoms (i.e., coughing, sneezing). Whenever possible, the mask would be worn by the symptomatic client.
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and policies change during a pandemic
• risks, benefits, and myths of seasonal influenza immunization
• the benefits of screening/surveillance • the importance of hand hygiene and proper hand hygiene technique
• cough etiquette • appropriate use of personal protective equipment
• caring for someone with influenza-like illness – including infection prevention and control measures (for staff working in residential or congregate living programs only)
• information/education for clients/residents, and strategies to encourage compliance.
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16.1.6 Supplies and Supply Chains Community mental health and addiction agencies should identify the type and quantity of supplies they will need during a pandemic wave, as well as potential suppliers. They should purchase and stockpile a four-week supply of personal protective equipment. (See Chapter 10 for a supplies and equipment template.) They should also have contingency plans in case traditional supply chains are disrupted. For example, clients may not be able to access methadone or other medications through hospital pharmacies so agencies will have to arrange another way to obtain prescriptions and medications (e.g., through arrangements with physicians and a local pharmacy). Congregate living programs should make arrangements with suppliers to maintain supplies of food, cleaning supplies and other materials. When agencies are serving clients who are dependent on food banks, they should work with the food banks to ensure that clients will continue to be able to get food during a pandemic.
16.1.7 Develop an HR Plan During a pandemic, community-based agencies may experience staff and skill shortages. The Ontario Health Plan for an Influenza Pandemic (OHPIP) supports a skills-based approach (for more information, see Chapter 8). As part of their planning, mental health and addiction agencies should identify:
• skills required to meet clients’ needs • staff who have those skills or could be trained to take on more responsibilities within their scope of practice
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• strategies that could be used to increase capacity (e.g., redeploying hospital-based staff to programs in the community, contracting staff from external agencies, extending working hours, calling staff back to work)
• other staff (e.g., clerical) who could be trained to assist with care
• volunteers and family members who could be trained to assist
• other organizations in the community that might be able to provide workers with the appropriate skills
• any labour (i.e., union), insurance or liability issues to be addressed
• the supports that staff and other workers may need to be able to work (e.g., transportation, accommodation, assistance with child care and other family responsibilities). Agencies should engage the Joint Occupational Health and Safety Committee or representative in pandemic planning to ensure plans include appropriate practice, communication and education.
16.1.8 Communicate with Staff, Clients, Families and Volunteers Most community-based mental health and addiction agencies will already have established plans and procedures for communicating with staff, clients, families and volunteers during an emergency. These plans should be reviewed to ensure that they will be appropriate during a pandemic. Agencies should maintain upto-date contact lists for staff, clients and families. To help ensure that all staff, clients and the public receive consistent messages
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from all parts of the health care system, mental health and addiction agencies should use influenza fact sheets and other materials provided by the local public health unit or the MOHLTC, including Important Health Notices. In addition, agencies should communicate with staff, clients and visitors about how services will be delivered during a pandemic, such as:
• encouraging clients/visitors to phone rather than come into the agency
• informing clients/visitors about any
develop a strategy for psychosocial support. The sector will also address outstanding issues, including:
• procedures, equipment, training and support required to maintain outreach and other essential community-based mental health and addiction services to highly vulnerable populations (e.g., homeless)
• the capacity of small community-based agencies to prepare for a pandemic
• a training strategy for the mental health and addictions workforce.
change in services or work practices
• providing as many services as possible by phone or other ways that reduce the need for people to congregate
• directing staff, clients, volunteers and visitors who have flu symptoms to appropriate services (e.g., Telehealth, flu centres) – and, if possible, discouraging them from entering mental health and additions settings. This information should be communicated on the agency’s voice mail and web site, and through clear signs on the doors. Directives During a pandemic, the Ministry of Health and Long-Term Care may issue directives about care, infection control or other issues. Information will be provided on how and when to apply these directives in community-based mental health and addiction settings.
16.1.9 Next Steps The community-based mental health and
addiction workforce has skills that will be valuable in helping manage the personal and social impact (i.e., fear, anxiety) of a pandemic. Representatives from this sector will work with the MOHLTC to
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16A. Community Health Services Tools
Contents Pandemic Preparedness Checklist for Community Health Services.................................................. 1 Mental Health and Addiction Services Pandemic Preparedness Checklist ...................................... 4
Ontario Health Plan for an Influenza Pandemic August 2008
Pandemic Preparedness Checklist for Primary Care Practices/Practitioners Task/Activity
Yes/No
Action Required
1. Planning 1.1. Does the practice have a plan for responding to an influenza plan? 1.2 Is the plan reviewed/updated regularly? 1.3 Does the office/organization have an influenza pandemic plan or a section in its influenza/respiratory infection outbreak plan that deals with the potential impact of an influenza pandemic? 1.4 Does the office/organization have an emergency or disaster plan? 1.5 Has the office/organization developed plans to ensure continuity of services in the event of internal emergencies (e.g., lack of water, hydro, food, and natural gas failure) related to a disruption of community services? 1.6 Are emergency/continuity plans reviewed/updated regularly? 1.7 Does the office/organization have an evacuation plan? 1.8 Is the evacuation plan reviewed/updated regularly? 1.9 Does the office/organization have a collaborative planning relationship with other health care organizations in the community (e.g., local public health unit, other primary care practices/community agencies, emergency medical services, acute care hospitals, long-term care homes)? 1.10 Have the planning partners developed criteria to determine where and how people will be cared for in the event of a pandemic?
2. Chain of Command/Command Centre 2.1. Does the office/organization have a designated Occupational Health and Safety representative and backup who are known to staff and available 24/7? 2.2 Are all staff aware of their roles/responsibilities during a pandemic outbreak? 2.3 Is there a designated area where staff can obtain information on /be alerted to a potential influenza pandemic? 2.4 Is there a chain of command for implementing the pandemic plan? (i.e., if administrator is not available, who is next in command?)
3. Resident Needs 3.1 Does the office/organization have an up-to-date assessment of patients/clients’ critical care needs? 3.2 Has the office/organization identified patients/residents who would require care during a pandemic? 3.3 Has the office/organization identified patients/clients at high risk of complications from influenza and identified strategies to reduce their risk? 3.4 Has the office/organization identified the skills/expertise required to meet patients’/clients’ non-influenza as well as influenza needs during a pandemic?
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4. Key Services 4.1 Has the office/organization identified key services that must be maintained during a pandemic? 4.2 Has the office/organization identified services that could be reduced or curtailed? 4.3 Does the office/organization have a mechanism to contact outside services (e.g., physiotherapy, occupational therapy) in the event of a pandemic outbreak?
5. Supply Chains 5.1 Has the office/organization identified the supplies required during an influenza pandemic? (See Chapter 10 for supplies template) 5.2 Does the home have contracts with local suppliers to provide medical equipment? 5.3 Will these suppliers be able to fulfill contracts during an influenza pandemic? If not, does the office/organization have a back-up source of supply? 5.4 Does the office/organization have access to an adequate supply of commonly used pharmaceuticals (e.g., Ciprofloxacin, Doxycycline, bronchial dilators)? 5.5 Has the office/organization identified and established relationships with other organizations outside the region as a means of accessing possible sources of needed pharmaceuticals, equipment, supplies, and staff? 5.6 Has the office/organization made arrangements to obtain and transport supplies for life sustaining services (e.g., for hemodialysis, peritoneal dialysis)?
6. Human Resources 6.1 Has the office/organization identified the skills required during a pandemic? 6.2 Has the office/organization identified the skills that existing staff – including administrative and non-patient care staff – can provide? 6.3 Does the office/organization have a staffing contingency plan in case 20 to 25% of staff are absent at the same time? 6.4 Does the office/organization have a policy for addressing work refusal? 6.5 Has the office/organization identified potential outside sources of human resources (e.g., nursing agencies, other community organizations, volunteers, family members)? 6.6 Has the office/organization developed plans to support staff during a pandemic (e.g., child care, transportation, psychosocial support, meals, accommodation, assistance with pet care)? 6.7 Has the office/organization – in collaboration with the Joint Health and Safety Committee or health and safety representative – developed education and training programs for staff?
7. Communications 7.1 Has the office/organization established a communication system with the local public health unit and other partners? 7.2 Does the office/organization have a plan for communicating with staff, volunteers and family members during a pandemic, including the person/s responsible for notifying staff and families?
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7.3 Does the office/organization have alternative methods of internal and external communication if the main method of communication is not available? 7.4 Is there an organized runner-messenger system as backup for communication system and power failures? 7.5 Has the office/organization developed procedures for handling requests for information from the media? Are these provisions consistent with the Public Health Information and Privacy Act (PHIPA)?
8. Security 8.1 Does the office/organizations have a procedure to minimize and control points of access in the building? 8.2 Does the office/organization have the ability to communicate with individuals immediately outside the building in the event access is restricted? 8.3 If outside staff are required to meet patient/client needs during a pandemic, are their credentials verified?
9. Traffic Flow and Control 9.1 Are there designated entrances and exits for vehicles and people? 9.2 Has the office/organization made provisions for deliveries (i.e.., supplies and equipment)? 9.3 Is there authorized vehicle parking? 9.4 Has the office/organization made arrangements for signs to direct patients/clients to proper entrances?
10. Surveillance 10.1 Does the office/organization promote annual immunization of staff and patients/clients? 10.2 Does the office/organization routinely assess patients/clients for febrile respiratory infection (FRI) and/or influenza-like illness (ILI) when applicable? 10.3 Does the office/organization encourage staff to report FRI or ILI symptoms?
11. Education and Training 11.1 Does the office/organization provide ongoing pandemic training and education? 11.2 Does the pandemic plan specify who is responsible for the training program? 11.3 Does the plan include methods for ramp up and quick training for new and altered roles (e.g., have policies and procedures been made, have job action sheets been developed)? 11.4 Does the office/organization provide pandemic education material at staff orientation to raise staff awareness? 11.5 Does the office/organization routinely provide training on the proper donning and removal of personal protective equipment?
Chapter #16A: Community Health Services Tools
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Mental Health and Addictions Pandemic Preparedness Checklist Task/Activity
Yes/No
Action Required
1. Planning 1.1 Does the agency/organization have an emergency or disaster plan? 1.2 Does the emergency plan include pandemic influenza? 1.3 Has the agency/organization developed plans to ensure continuity of services in the event of emergencies (e.g., lack of water, hydro, food, and natural gas failure) related to a disruption of community services? 1.4 Are emergency/continuity plans reviewed/updated regularly? 1.5 Does the agency/organization have an evacuation plan? 1.6 Is the evacuation plan reviewed/updated regularly? 1.7 Does the agency/organization have a collaborative planning relationship with other health care organizations in the community (e.g., local public health unit, emergency medical services, CCAC, acute care hospitals)? 1.8 Have the planning partners developed criteria to determine where and how people will be cared for in the event of a pandemic?
2. Organization 2.1 Are staff aware of their roles/responsibilities during an influenza pandemic? 2.2 Is there a designated area where staff can obtain information on/be alerted to a potential influenza pandemic? 2.3 Is there a chain of command for implementing the pandemic plan? (i.e., if an administrator is not available, who is next in command?)
3. Client Needs 3.1 Does the agency/organization have an up-to-date assessment of clients’ mental health and/or addiction needs? 3.2 Has the agency/organization identified clients who could be cared for in other settings if necessary? 3.3 Has the agency/organization identified clients at high risk of complications from influenza and identified strategies to reduce their risk? 3.4 Is information from ongoing client assessments incorporated into the client assessment plan? 3.5 Does the client assessment plan specify the skill/expertise required to meet the client’s needs?
4. Critical Services 4.1 Has the agency/organization identified services that must be maintained during a pandemic? 4.2 Has the agency/organization identified services that could be reduced or curtailed?
5. Supply Chains 5.1 Has the agency/organization identified the supplies required during the first four weeks of an influenza pandemic and a supplier? (See Chapter 10A for equipment and supplies template.)
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5.2 Will suppliers be able to fulfill contracts during an influenza pandemic? If not, does the agency/organization have a backup source of supply? 5.3 Does the agency/organization have plans to ensure clients continue to have access to prescribed medications and harm reduction equipment? (e.g., anti-depressants, methadone, needle exchange services) 5.4 Has the agency/organization developed plans to meet the practical needs of highly vulnerable clients (i.e., food, shelter)?
6. Human Resources 6.1 Has the agency/organization identified the skills that will be required during a pandemic? 6.2 Has the agency/organization identified the skills that existing staff – including administrative and other staff not directly involved in serving clients – will need? 6.3 Does the agency/organization have a staffing contingency plan in case 20 to 35% of staff fall ill? 6.4 Does the agency/organization have a policy for addressing work refusal? 6.5 Has the agency/organization identified potential outside sources of human resources (e.g., nursing agencies, other community organizations, volunteers, family members)? 6.6 Has the agency/organization developed plans to support staff during a pandemic (e.g., child care, transportation, psychosocial support, meals, accommodation, assistance with pet care)? 6.7 Has the agency/organization – in collaboration with the Joint Health and Safety Committee or health and safety representative – developed education and training programs for staff?
7. Communications 7.1 Has the agency/organization established a communication system with the local public health unit and other partners? 7.2 Does the agency/organization have a plan for communicating with staff, clients, volunteers and family members during a pandemic, including the person/s responsible for notifying staff and families? 7.3 Does the agency/organization have alternative methods of internal and external communication if the main method of communication is not available? 7.4 Has the agency/organization designated a media spokesperson? Is there a plan for this person to coordinate messages with the local public health unit? 7.5 Has the agency/organization developed procedures for handling requests for information from the media? Are these provisions consistent with the Public Health Information and Privacy Act (PHIPA)?
8. Traffic Flow and Control 8.1 Have provisions been made for internal traffic that allow for movement of clients through corridors and staff movement throughout their areas (e.g., designated unit/home area staff room instead of communal room)? 8.2 Does the agency/organization have plans to restrict access in affected areas of the home? 8.3 Will elevators be staffed and controlled? 8.4 Is there a designated entrance and exit for both vehicles and people?
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8.5 Has the agency/organization made provisions for deliveries (i.e., supplies and equipment)? 8.6 Does the agency/organization have the ability to control entry and exit to all parts of the facility? Has this process been tested? 8.7 Has the agency/organization made arrangements for signs to direct authorized personnel and visitors to proper entrances?
9. Screening/Surveillance 9.1 Does the agency/organization promote annual flu shots for staff and clients? 9.2 Does the agency/organization have plans to screen staff, clients, volunteers and visitors for symptoms of influenza-like illness (ILI) and refer them to Telehealth or a Flu Centre for assessment? 9.3 Does the agency/organization encourage staff to report ILI symptoms?
10. Education and Training 10.1 Does the pandemic plan specify who is responsible for educating staff? 10.2 Does the plan include methods for ramp up and quick training for new and altered roles (e.g., have policies and procedures been made, have job action sheets been developed)? 10.3 Does the agency/organization provide pandemic education material at staff orientation to raise staff awareness? 10.4 Does the program provide ongoing emergency/pandemic education to keep staff informed and procedures/practices up-to-date?
11. Relocation of Clients and Staff (in residential/congregate living settings) 11.1 Has the agency/organization made plans to relocate clients and staff in the event an area is designated for clients with ILI? 11.2 Has the agency/organization made arrangements with other organizations to relocate clients if the agency/organization is unable to meet clients’ needs (e.g., residential clients need hospital care for influenza, staff shortages threaten essential programs)? 11.3 Has the agency/organization identified temporary locations where clients and staff could be housed in the event of an evacuation (e.g., a power failure)? 11.4 Does the agency/organization have a plan to transport people to a temporary location?
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17. Acute Care Services The virus had made six hundred sailors and marines sick enough to require hospitalization, and more men were reporting ill every few minutes. The navy hospital ran out of beds. The navy began sending ill sailors to the Pennsylvania Hospital … Fourteen hundred sailors were now hospitalized with the disease. The Red Cross was converting the United Service Center … in to a five-hundred bed hospital for the sole use of the navy.” The Great Influenza, John M. Barry
Despite the fact that people who develop influenza symptoms will be encouraged to use Telehealth, their primary care practitioner or Flu Centres (if established), some will still present at emergency departments for assessment. (See Chapter 17A for sample assessment and admission forms). In addition, a significant proportion of people who develop influenza-related complications may require acute care. This chapter of OHPIP looks specifically at the management and allocation of acute hospital services during an influenza pandemic. In addition, the Ontario Hospital Association (OHA) has developed the OHA Pandemic Planning Toolkit for Small, Rural, and Northern (SRN) Hospitals, which is available free to hospitals in Ontario. For more information, see: http://www.oha.com.
from influenza and most likely to require hospitalization include:
• people of all ages with heart conditions and chronic lung conditions such as cystic fibrosis, asthma or emphysema
• residents of long-term care homes or other chronic care facilities due to environmental exposure, regardless of age or chronic conditions
• people with compromised immune systems from diabetes, other metabolic diseases, cancer, renal disease, anemia, HIV, sickle cell anemia
• children who are going on acetylsalicylic acid treatment for conditions like juvenile rheumatoid arthritis and at risk of Reyes Syndrome
• children younger than two years due to a general lack of immunity
• pregnant women in the second and 17.1 The Demand for Acute Care Based on FluAid, the forecasting model developed by the Centers for Disease Control in the United States, a 35% influenza attack rate will result in an estimated 61,253 total hospitalizations and 12,095 deaths over eight weeks (see Table 17.1). During annual influenza season, the people at higher risk for complications
Chapter #17: Acute Care Services
third trimester who will be at increased risk of cardio-respiratory diseases and stillbirths
• healthy people aged sixty-five years and older who will be at moderately increased risk of respiratory complications. Depending on the characteristics of the pandemic strain and the susceptibility of the population, an unknown proportion of the remaining Ontario population will develop health complications during the 17-1
Ontario Health Plan for an Influenza Pandemic August 2008
pandemic.
fluctuate during the year, according to the numbers of planned surgeries and treatments, as well as unplanned traumatic accidents, heart attacks, strokes, and high-risk births. Based on the MOHLTC Finance Information System report from March 31, 2004, Ontario hospital capacity includes:
17.2 Hospital Capacity The Flu Surge forecast assumes that each hospitalized influenza patient will require an average of either 5 (non-ICU) or 10 (ICU) days of hospital care with:
• 100% using an acute bed for 5 days
• 17,116 total acute beds
• 15% using ICU beds for 10 days
• 1,510 ICU beds, and
• 7.5% using ventilator support for 10
• 1,096 ventilator-supported beds
days.
(MOHLTC’s Critical Care Project survey in the fall of 2004, of Ontario hospitals).
Many hospitals in Ontario are currently operating at full capacity with very little surge capacity. Hospital bed numbers
Table 17.1: Impact of 35% Influenza Attack Rate on Hospital Capacity 35% Attack Rate - 8 Weeks Hospital Admission
Weekly admissions
Week 1 3,691
Week 2 6,152
Week 3 9,228
Peak admissions/day Hospital Capacity
ICU Capacity
Ventilator Capacity
# of patients in hospital
Week 5
11,689
11,689
1,821
1,821
Week 6
Week 7
Week 8
9,228
6,152
3,691
Week 9
Week 10
2,713
4,522
6,783
8,592
8,897
7,820
5,997
3,934
% capacity needed
16%
26%
40%
50%
52%
46%
35%
23%
# of patients in ICU
554
1,174
1,803
2,382
2,578
2,507
1,992
1,376
% ICU capacity needed
37%
78%
119%
158%
171%
166%
132%
91%
# patients on ventilators
277
587
902
1,191
1,289
1,254
996
688
25%
54%
82%
109%
118%
114%
91%
63%
# of influenza deaths
731
1,218
1,828
2,315
2,315
1,828
1,218
731
# of deaths in hospital
512
853
1,279
1,621
1,621
1,279
853
512
% usage of ventilators Deaths
Week 4
Notes: 1. All results showed in this table are based on most likely scenario. 2. Number of influenza patients in hospital, in ICU, and number of influenza patients on ventilator are based on maximum daily number in a relevant week. 3. Hospital capacity used, ICU capacity used, and % usage of ventilator are calculated as a percentage of total capacity available (see manual for details). 4. The maximum number of influenza patients in the hospital each week is lower than the number of weekly admissions because we assume a 5-day stay in general wards (see manual for details). 5. The CDC's FluSurge program (http://www.cdc.gov/flu/flusurge.htm) provides more specific detail with respect to hospital capacity during a pandemic and can display the impact on capacity over time depending on the duration of the pandemic (in weeks), which differs slightly form the FluAid program. While both FluAid and FluSurge require the user to enter population data for a particular community or area, both programs may yield different results in terms of the estimated number of deaths and hospitalizations for a given population. This may be because both programs use a slightly different age distribution for entry of population data.
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Ontario Health Plan for an Influenza Pandemic August 2008
Based on these Ontario bed numbers, at the peak of the pandemic, influenza patients will use an estimated 52% of all acute care beds, 170% of ICU beds and 117% of ventilator supported beds. Table 17.1 summarizes the demand for hospital services for influenza patients; it does not include the services required to treat patients with other health problems (e.g., trauma, heart attacks, strokes, high-risk births).
the health system.
The FluSurge estimates for hospitalizations during a moderate influenza pandemic are at least six times greater than typical hospitalizations for influenza and pneumonia during interpandemic periods (based on CIHI hospitalizations for influenza and pneumonia, from April 1996 to March 2004). During a severe pandemic, hospitalizations could be 9 to 10 times greater than during seasonal influenza.
Table 17.2 outlines approaches to optimizing hospital capacity and capability that, pending further advice from clinical experts and MOHLTC counsel, will be used in Ontario.
FluSurge used both influenza and pneumonia hospitalizations to estimate the impact of a pandemic because influenza has nonspecific symptoms and pneumonia is the most common health complication caused by influenza. Note: The FluSurge model is based on hospital data from the United States, which may not reflect the Canadian experience (i.e., hospital influenza admissions, ICU admissions, ventilator use and deaths may be lower in Canada). The model also does not take into account health care worker absenteeism (hospital staff will likely contract influenza at the same rate as the general population in their communities). MOHLTC will work with PHAC to develop a Canadian approach to pandemic modeling, and to test different pandemic scenarios (e.g., increased volume of Telehealth calls or increased use of protective equipment during the pandemic) and their impact on Chapter #17: Acute Care Services
Optimizing Hospital Capacity As alarming as the FluSurge numbers are, they do not take into account other factors that will affect hospital capacity including:
• the current demand for hospital services which is high without a pandemic: the daily utilization rate of ICU beds is over 90%
• illness among health care workers.
Developing Surge Capacity Based on the FluSurge estimate for a 35% attack rate, ICUs will be immediately affected, followed by rapidly increasing pressures on acute beds. By the end of the first week of the pandemic, influenza patients will require 37% of ICU bed and 16% of acute care bed capacity. To be able to meet pandemic demands, hospitals must develop a phased approach to surge capacity, including the deferral of noninfluenza care and the dynamic use of influenza triage and admission/discharge criteria constantly adjusted to hospital capacity. Recent reviews of emergency response arrangements in the United States suggest that 20% surge capacity is the maximum upper limit to any hospital “surge in place” response during major emergencies. This will vary according to local hospital resources. Table 17.3 outlines strategies that hospitals and their community partners can use to respond to the need for surge capacity. With a 35% attack rate, the phased development of surge capacity will not free up sufficient resources to meet needs during the peak periods of pandemic
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demand. After hospital surge capacity and other health system resources have been exhausted, mass emergency care will be declared in order to ensure the fair and equitable allocation of scarce resources, and maximize the benefit to the population at large. This approach will be consistent with the federal and provincial goals of pandemic influenza planning (i.e.,
to minimize serious illness and overall deaths). Since there are substantial political, legal, regulatory and logistical implications to declaring the shift to mass emergency, further advice will be sought from clinical experts and ministry counsel about the criteria for mass emergency care and guidelines for implementing that care once hospital surge capacity is exhausted.
Table 17.2: Approaches to Optimizing Hospital Capacity in Ontario Capacity
Activity Defer any services for non life-threatening conditions where no severe adverse health consequences are anticipated from the delay. Discharge Alternate Level of Care (ALC) patients to Long-Term Care homes when beds are immediately available. Discharge acute inpatients to home care when care can be provided safely in that environment.
Physical Capacity
Discharge acute patients to family and self care when care can be provided safely in that environment. Create “flex beds” from reserved beds or recently closed beds. Use ventilator capacity anywhere in the hospital where sufficient oxygen capacity exists (e.g. ER, post-anesthetic care units), cohort infectious patient and noninfectious patients. Deploy freed-up beds for influenza patients. Re-deploy clinical staff from deferred services. Defer staff holidays and leaves of absence until pandemic ends. For staff willing to work extra hours, establish 12-hour shifts up to the maximum recommended number of days per staff.
Hospital Staffing
Train non-clinical staff to provide support services such as meals, personal care, and patient movement for treatment, site cleaning and support for health care workers and their families, so the workers can do their job (e.g., child care, pet care). Recruit clinical agency staff in coordination with other hospitals in the immediate geographic area. Encourage members of the public to take home health care courses before the pandemic so they know how to prevent infection and provide supportive care for family members who are ill; train family members of hospital patients to provide home health care. Cross-train clinical staff for influenza care and other essential services during a pandemic and other large-scale emergencies.
Clinical Practices
Adopt clinical care practices to optimize hospital capacity, pending further development of clinical guidelines.
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Table 17.3: Strategies to Enhance Surge Capacity Surge Strategies
Surge Levels During an Influenza Pandemic
Response Level
IMS Command Function
Pre-Surge
Basic
• •
Staffed and operational beds open Some approved beds closed due to resource constraints
Intra facility
Hospital
Minor Surge
Enhanced
•
Open approved ICU and ventilator-supported beds as staff redeployment/recruitment permits Defer elective surgery up to 72 hours as per routine surge protocols Cohort/Isolate influenza patients in ER, acute units, and ICU/ventilator units Establish early discharges; home care transfers; ALC transfers to LTC Homes Open more ICU/ventilator beds where oxygen available (e.g., operating rooms or post anesthetic care units) Defer some treatment for non-life threatening condition if no severe adverse health consequences anticipated from the delay Defer all treatment for non-life threatening conditions where no severe adverse health consequences are anticipated from a delay
Intra facility
Hospital
Intra facility
Hospital
Inter facility
Region Province
No more beds available Maintain services for life-threatening conditions Triage for all treatment Mass Emergency Care
Inter facility
Province
5% to 10%
• •
Moderate Surge
Augmented
11% - 15%
• • •
Major Surge
Optimum
•
Over capacity
• • • •
16% - 20% Large Scale Emergency > 20%
Deferral of Non-Influenza Services When a pandemic is declared, hospitals will begin a phased deferral or scale-back of certain non-influenza services (e.g., elective surgeries, outpatient procedures) in order to ensure that essential services are there for both influenza and non-influenza care. By using a phased approach, hospitals will avoid unnecessary deferral of services before the full size of the pandemic is known, but will be able to act quickly to defer services as the pandemic grows. When making decisions to defer services, all sectors will:
• establish a senior multidisciplinary team to make the decisions and seek support from ethical and legal experts
• apply the ethical framework for decision making (Chapter 2)
• use consistent criteria that are flexible enough to allow local responses based on local demands and resources Chapter #17: Acute Care Services
• ensure their decisions are transparent. Note: All hospital service deferral decisions will be based on a careful and compassionate clinical assessment of each patient’s health condition, prognosis, and risk of infection during acute hospital care. Table 17.4 lists the criteria and indicator conditions that hospitals will use to identify services that can be deferred, and those that are essential and must be maintained.
17.3 Strategies to Build Critical Care Surge Capacity While the activities in Table 17.2 may divert some people from hospital, they do not address the need to manage critical care resources. During a pandemic, hospitals will use a series of strategies, such as code orange protocols and mass critical care, to build surge capacity (figure 17.1).
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Table 17.4: Criteria and Indicator Conditions for Deferring Hospital Services
Site of Care
Hospital Outpatient Surgery or Procedure
Hospital Emergency Department Care
Level 2
Level 3
Maintain services for non-life threatening conditions as long as resources are available, if severe adverse health consequences are anticipated from delay.
Maintain services for lifethreatening conditions throughout the influenza pandemic.
• • • •
Elective abdominal aortic surgery Cholecystectomy Hip/knee replacement Prostate transurethral resection Vasectomy Myringotomy Carpal tunnel release Cataract surgery
• • •
Superficial injuries Back or neck pain Extremity strain
• Hospital Inpatient Surgery or Procedure
Level 1 Defer services for non-life threatening conditions immediately if no severe, adverse health consequences anticipated by the delay.
• • •
• • • • •
Carotid endarterectomy Colectomy Thoracotomy Total prostatectomy Lumpectomy/mastectomy
• • •
Breast biopspy Chemotherapy Percutaneous coronary intervention (PCI) Cardiac catheterization Severe cuts Upper/lower respiratory infection Otitis media
• • • •
•
Initiation of mechanical ventilation
•
Initiation of mechanical ventilation
Notes to Table 17.4: These criteria are based on the three health care urgency categories developed by the Institute for Clinical Evaluative Sciences (ICES) to assess the impact of SARS on health services utilization. If the spread of influenza is gradual, scale-back may be time-sensitive, with some services deferred earlier than others according to the assessed impact from a delay. These recommendations mirror the Alberta Clinical Subcommittee report (2003, page 21), which state that the exact details of rationing health care resources cannot be anticipated in advance by an algorithm or list of tradeoffs. The report recommends a step-wise process, starting with decisions about elective surgery by the Chiefs of Surgery, Neurosurgery and Medicine, followed with shared decision-making among attending physicians, health care workers, senior physicians, the head of nursing, an ethicist and the Chief Executive Officer, for all other treatment.
Code Orange
The first response to a demand that exceeds routine critical care capacity is to implement an external disaster or “code orange” protocol. Most code orange protocols include a series of strategies (figure 17.1) that work together to provide short-term surge capacity and operate on an incident management system [IMS](3). Because responding to a pandemic that will last several weeks or months requires long-term sustainability rather than short-term surge capacity, not all “code orange” strategies will apply. For example:
• Hospitals often hold back a shift from
complement, but this will not be feasible during a pandemic which will last several weeks.
• Traditional mutual aid agreements (i.e., one organization lends staff or resources to another) will be of limited use as all hospitals will be facing the same challenges.
• Cancelling all elective and non-emergent services and surgeries will not be appropriate because, as we learned from SARS(4), failure to maintain other essential services during a prolonged emergency affects the broader health care system.
going home, thereby doubling staff
Chapter #17: Acute Care Services
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Ontario Health Plan for an Influenza Pandemic August 2008
Figure 17.1 Strategies to Build Critical Care Surge Capacity
Response Thresholds 200
>170%
175
~170%
ICU Capacity
150 125
~150%
“Code Orange ”
120 -130%
•Mutual aid agreements
100 75 50
•Call back staff •Cancel elective ORs
Normal Ops
•Open alternative care areas •Care team model •IMS
25
•etc
Mass Critical Care •Modified standard & delivery of care •Focus on key interventions •Expanded roles •etc
Mass Critical Care & “True Triage ” •Targeting Resources based on the Ultimate Ends of maximizing survival within the population •“do the greatest good for the greatest number ” •Dynamic balance between resources and needs
0 time
Scaling Back Elective Services
Scaling back elective services and surgeries can free up hospital areas, such as surgical intensive care units, endoscopic units, step-down units and post anaesthetic care units [PACU], that are well equipped to provide critical care for influenza and non-influenza patients. How much critical care capacity can be increased will depend largely on the availability of ventilators, and personnel skilled in managing critically ill patients.
cares for a group of patients. For example, a team of 2 ICU nurses supervising 3 stepdown nurses working with a respiratory therapist and a physician could care for 8 to 10 patients instead of the usual complement of 4 ICU nurses caring for 5 ventilated patients (i.e., 1:1 or 1:2 ratio). The care team model has proven effective in past emergencies(5;6). Figure 17.2 Team Model for Critical Care
Scaling back elective and non-urgent services can also provide additional personnel who may have skills transferable to critical care – particularly when a team care model is used (figure 17.2). In this model, health care providers who lack experience in a specific area can be supervised by those with the relevant experience. Instead of individual health care providers caring for one or two patients, a team that has a complete skill set and relevant experience collectively
Chapter #17: Acute Care Services
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Any scale back of elective and non-urgent procedures will require coordination among hospitals and between hospitals and community services so the system can continue to provide a full spectrum of services and continue to meet the population’s urgent health needs. Mass Critical Care
If after all these efforts, demands still exceed capacity, hospitals will adjust the type of care being provided to focus on key critical care interventions (i.e., mass critical care), including:
about how best to use scarce critical care resources to maximize the benefit for the community as a whole. This process, called “triage”, is only used after all the above strategies have been employed to maximize system capacity. Principles of Critical Care Triage Three key principles underpin critical care triage: 1.
A triage protocol for critical care is not aimed at deciding who will or will not receive care. All patients will be cared for. Every human life is valued and every human being deserves respect, caring and compassion. However, this does not mean that all patients will or should receive critical care. Those who do not receive critical care will not be abandoned; they will continue to receive alternative levels of care.
2.
Triage does not challenge or contravene ethical doctrine. In fact, triage is a practical application of ethics. Effective triage will ensure that fairness and justice prevail at a time when circumstances could leave people vulnerable to inequitable treatment. A thoughtful and carefully implemented triage protocol is based on clear and transparent criteria and can protect individuals from any inequities.
3.
In a resource-rich country like Canada, the type of triage described here is only ethically, legally and morally justifiable in an overwhelming crisis, such as an influenza pandemic, when all resources are in danger of being exhausted. This protocol is NOT a first step toward resource rationing under ordinary circumstances. It is
• basic modes of ventilation • hemodynamic support • antibiotics • disease specific countermeasures (i.e., thrombolysis)
• prophylaxis (e.g., DVT). Mass critical care(7;8) targets resources – including supplies and manpower – to optimize their effectiveness and efficiency.
17.4 Critical Care Triage The strategies discussed above will not be enough to respond to the number of people who will seek care during an influenza pandemic. CPIP notes that: “Prioritization of health resources at times of critical shortages will also need to be considered. Local community-based centers and hospitals need to take a multi-disciplinary approach and include ethical and legal considerations when developing any prioritization processes. If supplies, equipment, and access to intensive care must be rationed, a fair and equitable prioritization process will need to be established.”i Difficult decisions will have to be made
Chapter #17: Acute Care Services
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to be used only in extraordinary situations. Triage Overview During a disaster, including a pandemic, international law(9-11) requires jurisdictions to use methods to allocate resources that are equitable and maximize the benefit to the population at large(6). These methods are referred to as ‘triage’, but should not be confused with the prioritization “triage” systems(12) used routinely in emergency departments(13). To differentiate between the two, the term ‘TRUE Triage’ or ‘Targeting Resources to achieve Ultimate Ends’ has been suggested. The original concept of ‘triage’ was developed during wartime(11) when scarce resources were used to provide the maximum benefit to the population at large, even if it meant that individuals who might have been saved under other circumstances could not be treated optimally(13;14). Triage must be based upon established medical criteria, not factors such as socioeconomic status or political affiliation, and represents a dynamic balance between resource availability versus demand(13). When triage protocols are being developed, organizations must adhere to human rights, humanitarian laws(10) and to ethical practices, such as transparency and accountability(8) (see Framework for Ethical Decision Making, Chapter 2). As guardians of important resources, health care providers have to balance the needs of individuals with their responsibility to others in the community. The primary goal of triage is to “do the greatest good, for the greatest number”(13). No triage systems have been developed for use in critical care or medical illnesses; however, there are models that provide
Chapter #17: Acute Care Services
valuable lessons:
• Illness severity scoring systems(16-18) currently used in critical care research have reasonable abilities to predict ICU outcome, but they are cumbersome to use and impractical during a disaster when human resources are scarce. They have also not been validated for guiding or restricting treatment.
• Military triage systems(19-21) are good only as a model for critical care triage since they were devised specifically for trauma and not medical conditions or biological events.
• The ‘SEIRV’ triage system, developed for use in bioterrorism attacks, is used to categorize patients as susceptible, exposed, infectious, removed and vaccinated (SEIRV) (22). It provides many lessons that can be applied to the overall response to bioevents, but does not address resource allocation and has limited applicability when a virus is widespread in the community. The SEIRV system uses inclusion, exclusion and minimum qualifications for survival [MQS] to guide triage decisions, which should be used in all critical care triage systems.
• The Sequential Organ Failure Assessment score [SOFA](24) may be useful as a component of a triage tool. It has not been used to ration critical care resources but it was designed with this in mind(24). It is not disease specific; it uses general physiologic parameters that can be applied to a wide variety of conditions. The SOFA scale has been validated on a wide range of patients with various reasons for being in critical care and can be applied to all critical care patients as opposed to disease specific scoring systems. Preliminary drafts of this
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proposed tool were developed and included in OHPIP 2005. Accurate triage is critical to maximize survival. “Over-triage” – triaging patients inappropriately to critical care(13) – leads to inappropriate resource expenditures. Frykberg showed that over-triage of patients involved in terrorist bombings is directly related to overall increased mortality rates. Health care providers need real-time data about patient outcomes during a disaster in order to modify triage criteria and prevent under or over triage. Another mechanism to fine tune triage criteria is computer modeling based on databases of patients with similar illnesses (i.e., influenza) from nonbioevent occurrences.(23).
17.5 Draft Triage Protocol and Rationale A draft triage protocol is included in Chapter 17A: Acute Care Services Tools. It is not possible to develop a perfect triage protocol in advance of the pandemic when many factors (e.g., the pandemic strain, groups most likely to have poor outcomes) are unknown. Triage is a dynamic process that depends on both the demands and availability of resources, so the protocol will evolve over time. The primary goal of the draft protocol is to provide a starting point: guidance for making triage decisions during the early days and weeks of a pandemic. Although the triage protocol is designed for use during a pandemic, it applies to all patients being considered for admission to critical care: the pool of critical care resources must be shared by both those with and without influenza. Patients should be triaged when the physician or health care provider attending them believes that they meet the inclusion
Chapter #17: Acute Care Services
criteria for ICU. Patients at a centre without critical care services should be triaged remotely before being transferred, in order to minimize unnecessary transfers if they do not meet the criteria for admission to the ICU, or meet the exclusion criteria. The triage protocol has three main components. Inclusion Criteria Inclusion criteria identify patients who may benefit from admission to critical care. The inclusion criteria primarily focus on respiratory failure because the ability to provide ventilatory support is what will differentiate the ICU from other acute care areas such as step-down units. (With expanded care models developed as part of surge capacity, hemodynamic support and other advanced care will be provided in areas that have appropriate monitoring but do not typically provide that level of care; however, if hemodynamic support is not available elsewhere, it will qualify as inclusion criteria.) Exclusion Criteria Exclusion criteria can be broken down into three categories: 1) People who currently have a very poor prognosis/chance of survival even when treated aggressively in an ICU. These are the ‘hard’ boundaries that many intensivists recognize from their day-today care of patients. For example:
• people with severe burns with two or more high risk factors have a significant mortality risk(25)
• cardiac arrest patients who have unwitnessed or recurrent arrests and those who do not respond to prompt electrical interventions such as defibrillation or cardiac pacing, require 17-10
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significant resources but rarely survive to discharge(26)
• patients with a SOFA score of > 11 have a mortality rate in excess of 90% even with full critical care during a normal period. During a pandemic, mass critical care will focus on key intervention, which will likely result in equivalent or higher mortality rates than seen in studies validating the SOFA score. 2) People who will need a level of resource that simply cannot be met during a pandemic Some people may benefit from ICU care during a normal period, but only with intense use of resources and often prolonged care. During a pandemic, when the goal is to the most for the most, intense consumption of resources will be limited. For example, requiring large volume blood transfusions has, at this time, been listed as an exclusion criteria because many conditions requiring large transfusions are associated with high mortality rates, and the availability of blood products may be limited if we cannot identify “clean” or uninfected potential donors. 3) People with underlying significant and advanced medical illnesses whose underlying illness has a poor prognosis with high short-term mortality even without their current concomitant critical illness. Patients with advanced cancer or immunosuppression have very high resource requirements and are likely to suffer significant complications from influenza. Others in this cluster of exclusion criteria include patients who have end stage organ failure involving their heart, liver or lungs, based on cutoffs adopted from the transplant Chapter #17: Acute Care Services
literature(27;28)ii (i.e., mortality of >50% within the next one to two years as the baseline natural history of their organ failure). The risk from their illness combined with the fact that transplantation is unlikely during a pandemic means that these patients would require considerable resources and still have an overall low probability of survival. Minimum Qualifications for Survival The final aspect of the triage protocol deals with the “minimum qualifications for survival” [MQS]: a term borrowed from military triage protocols which represent a ceiling on the amount of resources that can be expended on any one individual. This is a concept foreign to western medical systems but required in war zones and refugee camps. For example, in a drought situation, in a refugee camp, physicians often find many dehydrated patients and a limited supply of saline solution to treat patients. A severely dehydrated patient on the verge of cardiovascular collapse needs possibly 10 or more liters of fluid to reverse the hypovolemic shock, which often, in the end, is not possible to do. Continuing to treat such a patient means that 5 or 10 other patients with early hypovolemia who could have been saved with 1 to 2 liters of fluid will also succumb to dehydration because the IV fluids were all used in a failed attempt to save a single individual. The alternative is to place a ceiling on the amount of resources that will be allocated to any one individual. The draft triage protocol includes MQS that require patients to be reassessed at 48 and 120 hours as well as an ongoing ceiling if a patient ever develops a SOFA score of ≥ 11 or any other exclusion criteria. The MQS attempts to identify early patients who are not improving and
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are likely to have a poor outcome. In routine practice, this poor outcome often isn’t identified until several days or weeks of intensive care have been invested in the patient: a situation that will not be possible during a pandemic, when resources are scarce. Prioritization of Patients The final component of the triage protocol is the prioritization of patients for potential admission to the ICU and ventilation. For ease of use, the common blue-red-yellow-green colour scheme was used.
• Blue patients are those who fall in to the expectant category and should not receive critical care. Depending on their condition and medical issues the patient may either continue to have curative medical care on a ward or palliative care.
• Red patients are highest priority for ICU admission and a ventilator if required. The aim is to find the balance between those who are sick enough to require the resource and will do poorly if they don’t receive it, and those who are unlikely to recover even if they do receive intensive care. Patients with a single organ failure, particularly those with respiratory failure due to influenza, and who otherwise have a very low SOFA score, are included in the red category – if they have no exclusion criteria. The goal is to optimize the effectiveness of the triage protocol so that every patient who receives critical care will survive.
• Yellow patients are very sick and may or may not benefit from critical care. They should receive care if the resources are available but not at the expense of denying care to someone in the red category who is more likely to
Chapter #17: Acute Care Services
recover. At the re-assessment points, patients who are improving are given high priority (red) for continued care, while those who are not showing signs of improvement or worsening are prioritized as yellow.
• Green patients should be considered for transfer out of the ICU.
17.6 Operationalizing Critical Care Triage Effective triage depends on an established, skilled and practiced infrastructure. The infrastructure required for critical care triage during a pandemic will be integrated with and built on the foundation for surge capacity. The infrastructure should include the following: Triage Officers Triage is challenging both clinically and psychologically, so those responsible for assessing patients and making triage decisions must have proper training before a pandemic as well as ongoing support throughout the pandemic. Prior experience shows that the best triage decisions are made by senior physicians with training in triage and significant clinical experience. In most circumstances a triage officer will assess patients in person; however, mechanisms should also be developed to give less senior or experienced physicians access to more senior/ experienced triage officers who can provide advice (e.g., building on existing infrastructure such as ‘NorthNetwork’ and ‘Telestroke’). Central Triage Committee While the triage protocol has been designed for ease of use, it will have to be modified as the pandemic evolves. These modifications will be based on an analysis of a large amount of data, and should not
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be decided by individual triage officers. To maintain public trust in the system as well as equity, solidarity and reasonableness (see Framework for Ethical Decision Making, Chapter 2), there should be a central committee familiar with the triage protocol to oversee triage during the pandemic and have command and control over the critical care resources in the field. Intelligence Good triage is based on good information (e.g., the demands on the system, resource availability, natural history of influenza, patient outcomes in critical care). The Central Triage Committee must have real time access to system and epidemiological data. Communications Network To implement the triage protocols, there must be an efficient communications network that allows two-way communications between the field and the command centre (e.g., the flow of data up to the central triage committee as well as new directives and advice down to the field). Protocol Activation Knowing when to activate a system is a challenge in any emergency. This task becomes even more challenging with an event like a pandemic, which is dynamic (evolving over time) rather then static (a single point in time). The same is true of knowing when to implement surge capacity strategies, mass critical care or any of the other pandemic response programs. If the triage protocol is implemented too late, many resources will be utilized by a few patients early in the pandemic, and the ICUs may quickly become gridlocked. However, given the
Chapter #17: Acute Care Services
implications of being declined ICU admission, implementing the protocol too early also has significant consequences for individual patients. The quality of the decision will depend on the availability of accurate information. When to activate the triage protocol is only half the question; the other half is how to implement the protocol. One approach would be to implement the protocol gradually by:
• expanding the breadth of the exclusion criteria in a graded manner
• applying the protocol to new patients being considered for admission as opposed to those already admitted to the ICU when the pandemic begins. If there is a rapid influx of patients who need critical care, the protocol may have to be applied retroactively to patients already admitted to the ICU. This requires further discussion.
17.7 Stockpiling of Antibiotics Most influenza-related deaths are caused by the development of complications and secondary infections, such as pneumonia. Many of these deaths can be avoided through prompt antibiotic treatment. The Provincial Infectious Diseases Advisory Committee (PIDAC) has identified antibiotics that hospitals should consider stockpiling as part of pandemic planning (see Table 17.5). The MOHLTC is also developing a provincial stockpile of antibiotics.
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Table 17.5: Antibiotics for Treatment of Infections Secondary to Influenza Antibiotic
Unit
Route
Amoxicillin/ Clavulinic acid (200)
70ml Bottles
Oral-liquid
Amoxicillin/ Clavulinic acid (125)
875/125 Tablets
Oral
Azithromycin
15ml bottles
Oral-liquid
Azithromycin
500mg
IV
Azithromycin
250mg
Tablet
Levofloxacin
250mg
Tablet
Levofloxacin
500mg
Tablet
Levofloxacin
250mg/ 50ml IV bags
IV
Levofloxacin
500mg/ 100ml IV bags
IV
Vanocomycin
1g Vials
IV
Cefuroxime
1.5g Vial
IV
Cefriaxone
2g Vials
IV
Cefriaxone
1g Vials
IV
17.7 Next Steps Occupational Health and Safety Tip Box Employers have developed and implemented appropriate measures, procedures and training for the protection of workers in consultation with Joint Health & Safety Committees (JHSC) or Health and Safety Representatives and Infection Prevention and Control resources. See measures in Chapter 7 for more information. Some examples of controls for acute care services include: HVAC system meets CSA or ASHRAE guidelines hand hygiene and cough etiquette signage plexiglass barriers
In developing the protocol, every effort was made to ensure that it reflects the OHPIP Ethical Framework for Decision Making. Access to critical care will be a contentious issue during a pandemic, and the triage protocol requires more consultation. The MOHLTC plans to:
• consult broadly with the health community
• educate the public about the need for triage during a pandemic
separate waiting and treatment areas for ILI and non-ILI patients
• develop the triage infrastructure
education and training for workers and supervisors
• encourage specific acute care services
appropriate IPC housekeeping practices personal protective equipment (based on risk assessment) Web resources: http://www.labour.gov.on.ca; http://www.ricn.on.ca; http://www.osach.on.ca; http://www.whsc.on.ca
to develop plans to maintain/manage services during a pandemic. See Chapter 17A for the plan developed by Cancer Care Ontario.
For more information on Occupational Health and Safety Measures and Infection Prevention and Control in Health Care Settings consult the OHPIP Chapter 7.
Chapter #17: Acute Care Services
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References (1) Osterholm MT. Preparing for the next pandemic. N Engl J Med. 2005; 352(18):1839-1842. (2)
(3)
(4)
(5)
Schoch-Spana M. Implications of pandemic influenza for bioterrorism response. Clin Infect Dis. 2000; 31(6):1409-1413. Christian MD, Kollek D, Schwartz B. Emergency preparedness: What every healthcare worker needs to know. Canadian Journal of Emergency Medicine 2005. Lim S, Closson T, Howard G, Gardam M. Collateral damage: the unforeseen effects of emergency outbreak policies. Lancet Infect Dis. 2004; 4(11):697-703. Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals' surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma. 2003; 54(1):147154.
(6)
Hick JL, Hanfling D, Burstein JL et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004; 44(3):253-261.
(7)
Rubinson L, Nuzzo JB, Talmor DS, O'Toole T, Kramer BR, Inglesby TV. Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care. Crit Care Med. 2005; 33(10):2393-2403.
(8)
Rubinson L, O'Toole T. Critical care during epidemics. Critical Care 2005.
(9)
Baskett PJ. Ethics in disaster medicine. Prehospital Disaster Med. 1994; 9(1):4-5.
(10) Domres B, Koch M, Manger A, Becker HD. Ethics and triage. Prehospital Disaster Med. 2001; 16(1):53-58. (11) VOLLMAR LC. Chapter 23. Military Medical Ethics. Military Medicine In War: The Geneva Conventions Today. 2005. (12) Murray M, Bullard M, Grafstein E. Revisions to the Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines. Can J Emerg Med. 2004; 6(6):421-427. (13) Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma 2002; 53:201-212. (14) Chapter 8: Ethical issues. Health Disaster Management: Guidelines for Evaluation and Research in the "Utstein Style". 2002. (15) Ontario Ministry of Health and Long Term Care. Ontario Health Pandemic Influenza Plan. 2005. Ref Type: Electronic Citation (16) Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. 1981; 9(8):591-597. (17) Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985; 13(10):818-829. (18) Knaus WA, Wagner DP, Draper EA et al. The APACHE III prognostic
Chapter #17: Acute Care Services
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Ontario Health Plan for an Influenza Pandemic August 2008
system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991; 100(6):1619-1636. (19) Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE– a new method of dynamic triage for victims of a catastrophic earthquake. Prehospital Disaster Med. 1996; 11(2):117-124. (20) Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care. 2001; 5(2):197199. (21) Romig LE. Pediatric triage. A system to JumpSTART your triage of young patients at MCIs. JEMS. 2002; 27(7):52-53.
(26) Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ. 2002; 167(4):343-348. (27) International guidelines for the selection of lung transplant candidates. The American Society for Transplant Physicians (ASTP)/American Thoracic Society(ATS)/European Respiratory Society(ERS)/International Society for Heart and Lung Transplantation(ISHLT). Am J Respir Crit Care Med. 1998; 158(1):335-339. (28) Devlin J, O'Grady J. Indications for referral and assessment in adult liver transplantation: a clinical guideline. British Society of Gastroenterology. Gut. 1999; 45 Suppl 6:VI1-VI22.
(22) Burkle FM, Jr. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. Emerg Med Clin North Am. 2002; 20(2):409-436. i
(23) Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001; 38(5):541-548.
Canadian Pandemic Influenza Plan, February 2004, pg 354.
ii
National Protocol For Assessment Of Cardiothoracic Transplant Patients. March 2002. Prepared by the UKT Cardiothoracic Advisory Group. A special health authority of the national health service. UK Transplant, Fox Den Road, Stoke Gifford, BRISTOL, BS34 8RR
(24) Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001; 286(14):1754-1758. (25) Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med. 1998; 338(6):362-366.
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17A. Acute Care Services Tools Contents Draft Critical Care Pandemic Triage Protocol ........................................................................................1 Secondary Assessment for Hospital – Adult ..........................................................................................5 Influenza Admission (Adult – Hospital) .................................................................................................9
Ontario Health Plan for an Influenza Pandemic August 2008
Draft Critical Care Pandemic Triage Protocol Any patient being assessed for possible admission/transfer to critical care will undergo the following steps in assessment:
decreased urine output, or other end organ failure) refractory to volume resuscitation requiring vasopressor/inotrope support that cannot be managed on the ward.
Step 1: Assess to see if patient meets inclusion criteria
• If patient meets inclusion criteria proceed to Step 2.
• If patient does NOT meet inclusion criteria reassess patient in future if there is deterioration in clinical status. Step 2: Assess for exclusion criteria
Exclusion Criteria The patient is excluded from admission/transfer to Critical Care if ANY of the following are present:
• Severe trauma (needs to define further).
• Severe burns:
• If no exclusion criteria proceed to Step
•
3.
• If exclusion criteria PRESENT ‘Blue tag’ patient, do not transfer to critical care. Continue current level of care or palliate as indicated (see palliative care guidelines). Step 3: Proceed to triage tool, Initial Assessment
•
i. Age > 60 years old. ii. TBSA > 40%. iii. Inhalation injury. Cardiac Arrest: •
Unwitnessed cardiac arrest.
•
Witness cardiac arrest not responsive to electrical therapy (defibrillation, cardioversion, or pacing).
•
Recurrent cardiac arrest.
Note: This triage protocol applies to ALL patients undergoing assessment for possible admission/transfer to critical care. Inclusion Criteria The patient must have 1 of criteria A or B
A patient with any two of the following:
• Severe cognitive impairment.
A. Requirement for invasive ventilatory support:
• Advanced untreatable neuromuscular
• Refractory Hypoxemia (SpO2 < 90% on
• Metastatic Malignancy.
non-rebreather mask/ FiO2 > 0.85).
• Respiratory Acidosis with pH < 7.2. • Clinical evidence of impending respiratory failure.
• Inability to protect or maintain airway. B. Hypotension:
• Hypotension (SBP < 90 or relative
disease.
• Advanced & irreversible immunocompromise.
• Severe and irreversible neurologic event/condition.
• Endstage organ failure meeting following criteria: •
Cardiac.
hypotension) with clinical evidence of shock (altered level of consciousness, Chapter #17A: Acute Health Services Tools
17A-1
Ontario Health Plan for an Influenza Pandemic August 2008
•
i. NYHA class III or IV heart failure. Lung:
•
•
i. COPD with FEV1 < 25% predicted, baseline PaO2 < 55 mmHg, or secondary pulmonary hypertension. ii. CF with postbrochodilator FEV1 < 30% or baseline PaO2 < 55 mmHg. iii. Pulmonary fibrosis with VC or TLC < 60% predicted, baseline PaO2 < 55, or secondary pulmonary hypertension. iv. Primary pulmonary hypertension with NYHA class III – IV heart failure, or right atrial pressure > 10 mmHg, or mean pulmonary arterial pressure of > 50 mmHg.
Liver:
i. Child Pugh Score ≥ 7. Age > 85 years old.
• Requirement for transfusion of > 6 units PRBC within 24 hour period.
• Elective palliative surgery. Appeals/Exemptions In rare circumstances where the triage officer and/or the attending intensivist feels that, at the initial assessment, a patient may be triaged as ‘Blue’ due to an anomaly of the protocol and in all likelihood has a significantly lower risk of mortality, the central triage committee should be consulted. In some circumstances, the committee may authorize a 48 hour trial of care after which the patient will be re-triaged according to protocol.
SOFA Scale Variable
0
1
2
3
4
>400
≤ 400
≤ 300
≤ 200
≤ 100
Platelets, x 10 /µL (x 106/L)
> 150
≤ 150
≤ 100
≤ 50
≤ 20
(> 150)
(≤ 150)
(≤ 100)
(≤ 50)
(≤ 20)
Bilirubin, mg/dL (µmol/L)
<1.2 (< 20)
1.2-1.9 (20 – 32)
2.0-5.9 (33 – 100)
6.0-11.9 (101 – 203)
>12 (> 203)
Hypotension
None
Glasgow Coma Score
15
Creatinine, mg/dL (µmol/L)
PaO2/FiO2 mmHg 3
Dop > 5,
Dop > 15,
Dop ≤ 5
Epi ≤ 0.1, Norepi ≤ 0.1
Epi > 0.1 Norepi > 0.1
13 – 14
10 – 12
6–9
<6
<1.2
1.2-1.9
2.0-3.4
3.5-4.9
>5
(< 106)
(106 – 168)
(169 – 300)
(301 – 433)
(> 434)
MABP < 70 mmHg
Dopamine [Dop], epinephrine [Epi], norepinephrine [Norepi] doses in ug/kg/min SI units in brackets Adapted from: Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001; 286(14):1754-1758.
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Ontario Health Plan for an Influenza Pandemic August 2008
Critical Care Triage Tool (Initial Assessment) Colour Code
Criteria
Blue
Exclusion Criteria* or SOFA > 11*
Red
SOFA ≤ 7 or
Priority/Action Medical Mgmt +/- Palliate & d/c from CC
Highest
Single Organ Failure
Yellow
SOFA 8 – 11
Intermediate
Green
No significant organ failure
Defer or d/c, reassess as needed
* If exclusion criteria or SOFA > 11 occurs at anytime from initial assessment to 48 hours change triage code to Blue and palliate. CC = critical care d/c = discharge
Critical Care Triage Tool (48 Hour Assessment) Colour Code
Criteria
Priority/Action
Exclusion Criteria Blue
or SOFA > 11 or
Palliate & d/c from CC
SOFA 8 – 11 no Δ Red
SOFA score < 11 and decreasing
Highest
Yellow
SOFA < 8 no Δ
Intermediate
Green
No longer ventilator dependant
d/c from CC
Δ = change CC = critical care d/c = discharge
Chapter #17A: Acute Health Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Critical Care Triage Tool (120 Hour Assessment) Colour Code
Criteria
Priority/Action
Exclusion Criteria* or Blue
SOFA > 11* or
Palliate & d/c from CC
SOFA < 8 no Δ Red
SOFA score < 11 and decreasing progressively
Highest
Yellow
SOFA < 8 minimal decrease (< 3 point decrease in past 72h)
Intermediate
Green
No longer ventilator dependant
d/c from CC
* If exclusion criteria or SOFA > 11 occurs at anytime from 48 – 120 hours change triage code to Blue and palliate. CC = critical care d/c = discharge
Chapter #17A: Acute Health Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
This patient may have influenza! (hand hygiene, gloves, eye protection, N95 respiration, and gown if close contact).
Clinical Case Definition: When influenza is circulating in the community, the presence of fever and cough of acute onset are When circulating the community, the presence of fever and cough onset goodinfluenza predictorsisof influenza.in The positive predictive value increases when feverofisacute higher thanare 38C good predictors of influenza. The positive predictive value increases when fever is higher than 380C and when the onset of clinical illness is acute (less 48 hours after the prodromes). Other symptoms, and when the onset clinical illness is acute (less hours after the Other such as sore throat,ofrhinorrhea, malaise, rigors or 48 chills, myalgia andprodromes). headache may alsosymptoms, be present. such soredefinitions throat, rhinorrhea, malaise, or chills, may myalgia and headache also present. Anyascase developed prior torigors the pandemic need to be modifiedmay once thebe pandemic Any case definitions prior to the patient pandemic need to beillness modified oncean the pandemic occurs. A history ofdeveloped contact with another withmay influenza-like or with influenza case occurs. A history of contact with another patient influenza-like with an influenza confirmed by the laboratory should be with sought. If present,illness it is ofordiagnostic value. case confirmed by the laboratory should be sought. If present, it is of diagnostic value.
Secondary Assessment for Hospital - Adult Assessor’s name (first name, last name)
Date (dd/mm/yy)
Qualifications
/
Time (hh : mm)
/
:
Section 1 - Assessment 1a. If patient meets any of the following criteria, apply oxygen and notify MD immediately - (check all that apply) SpO2 ! 90%
Inability to protect airway
RR > 30/min
Clinical evidence of severe respiratory distress or impending respiratory failure
Systolic BP < 90mmHg
HR < 40/min or >120/min
1b. If none of the above criteria are present - complete the following Orders 1. CBC, K+, Na+, CI-, HC03, Cr, Ur, glucose, AST, ALT, ALP, Tbili, CK 2. EKG & troponin if history of chest pain or cardiac disease 3. CXR (PA & lat) if SOB or cough or SpO2 < 95% or crackles on chest auscultation 4. Proceed with secondary assessment once above results available
4435-45 (07/05)
Chapter #17A: Acute Health Services Tools
Completed Date (dd/mm/yyyy)
/
/
/
/
/
/
/
/
Time (hh : mm)
Initials
: : : :
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Section 1 - Assessment continued …. 1c. If none of the boxes in section “1a.” are checked, complete the following - (check all of the following that apply)
Column A
Column B
Acute confusion
Evidence of pneumonia
Hgb < 80g/L
Column C Age > 65 years pregnancy
WBC < 2.5 or > 12
New cough producing sputum, or change in sputum quality
> 15% bands cells or `left shift’ on CBC
Crackles or evidence or consolidation on chest examination.
congestive heart failure
Infiltrates on chest xray
immunosuppression
Plt < 50 000/L Na+ < 125mEq or > 148mEq
chronic lung disease chronic renal failure haematological abnormalities
K+ < 3mEq or > 5.5mEq
diabetes
Ur > 10.7mmol/L
hepatic disease
Cr > 150mmol/L glucose < 3.8 or > 13.9mmol/L CK > 1000 Requires supplemental oxygen Sp02 < 90% on room air Requires Intravenous fluids/medications Acute cardiac/hemodynamic deterioration EKG evidence of ischemia Positive Troponin (cardiac enzymes) unable to self-care/lack of home supports
If one or more boxes in Column A are checked, this patient requires admission. • Notify admission team
If only Column B is checked, this patient can be discharged with appropriate outpatient treatment. • go to section 2 If both Columns B and C have boxes checked this patient requires admission. • Notify admission team If only Column C is checked, this patient can be discharged with appropriate outpatient treatment. • go to section 2 4435-45 (07/05)
Chapter #17A: Acute Health Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient: Address:
/
Date of birth:
/
Age:
MRN: Home: (
Telephone:
)
-
Business: (
)
-
Section 2 - Discharge with Out-Patient Management Calculation of Creatine clearance [ 140 - _______ (age in years) ] x ________ ( wt in kg ) X 1.2 = _______.x [ 0.85 if female ] = _____________________ ml/min (Cr in !mol/L ) Levofloxacin 500 mg PO od x 10 days If CrCl > 50ml/min*
Number of pills provided upon discharge
or Cefuroxime 500 mg PO q12h x 10 days and Azithromycin 500 mg PO x 1, then 250 mg PO od x 4 days Levofloxacin 500 mg PO x 1 then 250 mg PO od x 10 days or
If CrCl 25 - 49
First dose given Time (hh:mm)
Cefuroxime 500 mg PO q12h x 10 days and Azithromycin 500 mg PO x 1, then 250mg PO od x 4 days
:
Assessor’s initials
Levofloxacin 500g PO x 1 then 250 mg PO q48h x 10 days or
If CrCl 10 - 24
Cefuroxime 500 mg PO q12h x 10 days and Azithromycin 500mg PO x 1, then 250 mg PO od x 4 days Levofloxacin 250g PO q48h x 10 days or
If CrCl < 10
Cefuroxime 500 mg PO q24h x 10 days and Azithromycin 500mg PO x 1, then 250 mg PO od x 4 days Did this patient’s influenza symptoms start within the last 48 hours? No, complete section 3 Discharge with Follow-up yes
Number of pills provided
oseltamivir 75mg PO bid* x 5 days (oseltamivir is recommended as first line treatment for all patients unless CrCl is < 10ml/min, or on dialysis) *change dose to once daily if CrCl 10-30ml/min.
OR
:
zanamivir 10 mg ( 2 inhalations) bid x 5 days (recommended if CrCl < 10ml/min, on dialysis or if pregnant or breastfeeding). Warning: zanamivir is not recommended for patients with asthma or COPD Physician name (first name, last name)
First dose given of oseltamivir Time (hh:mm) Assessor’s initials
Physician signature
First dose given of zanamivir Time (hh:mm) Assessor’s initials :
CPSO number
Date (dd/mm/yyyy)
/ **Original Prescription (this page): Patient 4435-45 June 21, 2006
Chapter #17A: Acute Health Services Tools
/
Copy/duplicate : Patient chart Ministry of Health and Long-Term Care
17A-7
Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient: Address:
Date of birth:
/
/
Age
MRN Telephone::
Home: (
)
-
Business: (
)
-
Section 3 - Discharge with Follow-up Follow-up planned:
(in preferred order (ie. Patient does not have access to a telephone, clinical factors etc.)).
Check if antivirals received Primary care (copy assessment form for patient to bring to re-assessment) Assessment centre (copy assessment form for patient to bring to re-assessment) Check if antibiotics received Self care instruction sheet provided and reviewed Discharge instruction sheet provided and reviewed Assessor’s (first name, last name)
4435-45 June 21, 2006
Chapter #17A: Acute Health Services Tools
Discharge date (dd/mm/yyyy) /
/
Discharge date (dd/mm/yyyy) /
/
Discharge time (hh : mm) : Discharge time (hh : mm) :
Assessor’s signature
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient:
Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
This patient may have influenza! (hand hygiene, gloves, eye protection, N95 respirator, and gown if close contact).
Influenza Admission (Adult – Hospital)
Date (dd/mm/yyyy)
/
/
Time (hh : mm)
:
Section 1 - History of Presenting Illness See Primary Assessment Sheet attached Additional history:
Section 2 - Past Medical History Diabetes (type 1)
CHF
Coronary Artery Disease
Stroke
Diabetes (type 2)
COPD
Asthma
Epilepsy
Hypothyroid
Hyperthyroid
Hypertension
Hyperlipidemia
Atrial Fibrillation
Chronic renal failure
Peripheral vascular disease
GERD
Other, specify:
Section 3 - Past Surgical History CABG
Angioplasty
Joint replacement:
Cataract
Cholecystectomy
Appendectomy
Hysterectomy
Hernia repair
Other, specify: Physician name (first name, last name)
Physician signature
MD.
MD.
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient:
Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Section 4 - Allergies 1.
reaction:
2.
reaction:
3.
reaction:
Section 5 - Medication (drug taken at home) If further space is required, complete and attach Medication List Appendix Drug - medication name, dose, route, frequency
To be ordered in hospital
Carried (hh : mm)
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
yes
no
:
Initials
Section 6 - Substance History Smoking - number of packyears
Alcohol – number of drinks/week
(consider nicotine patch)
(if more than 14/wk or daily consumption consider alcohol withdrawal prophylaxis)
Section 7 - Social Supports Live alone / no support (notify social work and flag for discharge planning) Lives with others/support available
Supportive Care
Physician name (first name, last name)
Long-term Care
Physician signature
MD. 4436-45 (07/05)
Chapter #17A: Acute Health Services Tools
MD. Ministry of Health and Long-Term Care
17A-10
Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient:
Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Section 8 - Nursing Assessment
Section 9 - MD Physical Exam 1. Head and Neck Mucous membranes
moist
dry
Neck
supple
stiff/rigid
Conjunctiva
pink
pale
Respiratory effort
normal
distressed
Expansion
sym
asym
Percussion
normal
dull (location):
Auscultation
clear
complete the lung chart
Other findings to note:
2. Chest
Z Physician name (first name, last name)
= wheeze
= crackles
= breath sounds
Physician signature
MD. 4436-45 (January 19, 2007)
Chapter #17A: Acute Health Services Tools
MD. Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient:
Address:
/
Date of birth:
/
Age:
MRN: Home: (
Telephone:
)
-
Business: (
)
-
Section 9 - MD Physical Exam continued … 3. CVS:
vi. Abdomen:
JVP
cm above sternal angle
Carotid pulse
normal
decreased
bounding
Apex
normal
S1
normal
S2
normal
S3
absent
present
S4
absent
present
Rub
absent
present
Murmur
absent
present complete the following chart
Bowel sounds
normal
Palpation
soft
guarding
non-tender
tender
Percussion
normal
4. Extremities: Cyanosis
absent
present
Peripheral pulses
present
absent
Clubbing
absent
present
Peripheral edema
present
absent
5. CNS: Level of consciousness
alert
drowsy
unresponsive
Orientation
person
place
time
Cranial nerves
normal
abnormal =
Reflexes
normal
abnormal =
Motor
normal
abnormal =
Sensation
normal
abnormal =
Section 10 - Laboratory Review normal
abnormal note abnormalities below AST
LDH
ALT
CK
ALP
amylase
Tbili
Troponin
INR
PTT
Misc
4436-45 (January 19, 2007)
Chapter #17A: Acute Health Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Physician name (first name, last name)
Physician signature
MD.
4436-45 (January 19, 2007)
Chapter #17A: Acute Health Services Tools
MD.
Ministry of Health and Long-Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient:
Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Section 11 - Orders
4436-45 (January 19, 2007)
Chapter #17A: Acute Health Services Tools
Ministry of Health and Long-Term Care
17A-14
Ontario Health Plan for an Influenza Pandemic August 2008
Completed Time (hh : mm)
Orders 1. 2.
Admit to – name of facility Diagnosis - suspected
Team
: :
influenza
DAT
healthy heart
renal
NPO
Diet
4.
Activity
AAT
bed rest
other
5.
Vitals
q4h
q6h
other
:
other
diabetic diet kJ/d
3.
: :
saline lock with flush as per protocol 6.
IV*
IV
at
Cc/h with
*IV rate must be re-assessed every 24h
7.
Oxygen
Initials
MEq KCI/L**
:
**electrolytes & Cr q 24h if IV contains KCI
nalsal prongs at
Ipm
venturi mask at
Fi02 *
simple face mask at
Ipm*
:
use if COPD
*to keep Sp02 > 90%, notify MD if > 50% Fi02 or non-rebreather required, Discontinued 02 if Sp02 > 92% on room air
8.
Antivirals – if symptoms onset <
48 hours
oseltamivir 75mg PO bid x 5 days (olsetamivir is recommended as first line treatment unless CrCI<10ml/min, on dialysis, or if pregnant/breastfeeding)
:
zanavamir 10 mg (2 inhalations) bid x 5 days (recommended if CrCI<10ml/min, on dialysis or if pregnant or breastfeeding. WARNING: zanamivir is not recommended for patients with asthma or COPD) 9.
Oral Antibiotics (IF PATIENT HAS EVIDENCE OF PNEUMONIA)
Levofloxacin 500 mg PO od x 10 days If CrCI > 50ml/min
or
If CrCI 25 - 49
or
If CrCI 10 - 24
or
If CrCI < 10
or
:
Cefuroxime 500 mg PO q12h x 10 days and Azithromycin 500 mg PO x 1, then 250 mg PO od x 4 days Levofloxacin 500 mg PO x 1 then 250 mg PO od x 10 days
:
Cefuroxime 500 mg PO q12h x 10 days and Azithromycin 500 mg PO x 1, then 250 mg PO od x 4 days Levofloxacin 500 mg PO x 1 then 250 mg PO q48h x 10 days
:
Cefuroxime 500 mg PO q12h x 10 days and Azithromycin 500 mg PO x 1, then 250 mg PO od x 4 days Levofloxacin 250 mg PO q48h x 10 days
:
Cefuroxime 500 mg PO q24h x 10 days and Azithromycin 500 mg PO x 1, then 250 mg PO od x 4 days
Physician name (first name, last name)
Physician signature
MD.
4436-45 (January 19, 2007)
Chapter #17A: Acute Health Services Tools
MD.
Ministry of Health and Long-Term Care
17A-15
Ontario Health Plan for an Influenza Pandemic August 2008
Name of patient:
Address:
/
Date of birth:
/
Age:
MRN: Telephone:
Home: (
)
-
Business: (
)
-
Section 11 - Orders continued… Completed Time (hh : mm)
Orders 10.
IV Antibiotics (IF PATIENT HAS EVIDENCE OF PNEUMONIA AND CANNOT TAKE ORAL ANTIBIOTICS)
Levofloxacin 500 mg IV q 24h x 10 days If CrCI > 50ml/min
or
If CrCI 25 - 49
or
If CrCI 10 - 24
or
If CrCI < 10
or
:
Cefuroxime 750 mg PO q 8h x 10 days and Azithromycin 500 mg IV x 5 days Levofloxacin 500 mg IV x 1 then 250 mg IV q 24h x 10 days
:
Cefuroxime 750 mg IV q 8h x 10 days and Azithromycin IV x 5 days Levofloxacin 500 mg IV x 1 then 250 mg IV q 48h x 10 days
:
Cefuroxime 750 mg IV q 12h x 10 days and Azithromycin 500mg IV x 5 days Levofloxacin 250 mg IV q 48h x 10 days
11.
Initials
:
Cefuroxime 750 mg IV q 24h x 10 days and Azithromycin 500mg IV x 5 days
Bronchodilators ventolin 2 puffs q4h and ventolin 2 puffs q1h prn and atrovent 4 puffs q4h
:
or combivent 2 puffs q4h and ventolin 2 puffs q1h prn 12. 13. 14.
! ! acetaminophen 650 mg PO/PR q6h prn
flovent 500 µcg q12h via aerochamber Antiemetics Dimenhydrinate 50mg PO/IV/IM q4h prn for nausea Antipyretic/analgesic Investigations (no routine bloodwork required) CBC, lytes, Cr, glucose q
h x 3 then R/A
AST, ALT, ALP, T bili, CK, LDH q INR, PTT q
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Troponin q8h x 3 EKG daily x
Days and prn with chest pain
Order if baseline labs are abnormal or if history indicates 15.
DVT Prophylaxis
! compression stockings until patient ambulating ! heparin 5000u SC bid until patient ambulating*
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*hold and notify MD if history of heparin induced thrombocytopenia or other contraindications (i.e./patient on alternative blood thinner) Physician name (first name, last name)
Physician signature
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Chapter #17A: Acute Health Services Tools
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Chapter #17A: Acute Health Services Tools
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17B. Cancer Care
Contents
Guidelines for Clinical Care of Patients with Cancer During an Influenza Pandemic.................... 1 Cancer Service Planning Assumptions ............................................................................................... 1 Clinical Programs................................................................................................................................... 1 Preamble .................................................................................................................................................. 1 Priority Classification of Cancer Care Needs..................................................................................... 2 Clinical Program Criteria for Classifying Patient Needs ................................................................. 4 Criteria to determine whether a program/service should cease operating .................................. 8 Cancer Program Operational Recommendations.............................................................................. 9
Ontario Health Plan for an Influenza Pandemic August 2008
Guidelines for Clinical Care of Patients with Cancer During an Influenza Pandemic Cancer Service Planning Assumptions This plan is for cancer patients who do not have influenza but require cancer treatment and/or services. The process for patients with influenza symptoms or urgent medical (non cancer) issues will be as per the local hospital pandemic plan. (For general planning assumptions for an influenza pandemic, see OHPIP Chapter 3.)
Clinical Programs These consist of: 1. Screening Programs •
Ontario Breast Screening Program
•
Familial Oncology / Genetics Clinics
2. Palliative Care Program 3. Radiation Treatment Program 4. Surgical Oncology Program 5. Systemic Therapy Program
Preamble A system to determine a priority for consultation and treatment of patients with cancer is necessary to have a consistent approach across the province. It is important to avoid, as far as possible, having different levels of care. Currently there are no disease specific influenza pandemic plans available. A cancer patient priority classification has been developed by the clinical programs to assist cancer programs in the management of patients referred with a cancer diagnosis.
Chapter #17B: Cancer Care
Local or regional circumstances and the availability of resources may influence a cancer program’s ability to follow the criteria. If some regions are hit harder than others, a re-referral system is recommended for patients with potentially life-threatening or rapidly progressing curable cancers. There is a definite possibility that centres will have the capacity to treat only a small proportion of patients, so an ethical framework for decision making is required. Ethics Guidelines In a situation of very limited human resources the principle of justice will be the prominent principle to which one will appeal within a context of respect for the patient’s autonomy (respecting the patient’s wishes regarding his or her treatment), beneficence (doing good for the patient) and non-malficence (not harming the patient unnecessarily). The principle of justice, which connotes treating people fairly, was first articulated by Aristotle as “Equals ought to be treated equally and unequals unequally.” Whereas everyone is morally equal, not everyone is equal in some other ways. For instance, children of very wealthy parents are less likely to need government help in paying for their education. People who are well need less medical care than those who are sick. Someone with a cold and sore throat in the ER ought not to be seen before the person with chest pain because his need is, in all probability, less than the person who may be having a myocardial infarct. Our criterion for deciding who is “more or
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less” equal in medical care is need and efficacy of treatment. In some instances this is very easy to determine – and in some instances, not at all easy. In the situation of cancer care, many have a life threatening condition and therefore can be argued to be in equal need. However, even within the context of cancer there are some who can reasonably wait longer than others for care.
Priority Classification of Cancer Care Needs In this document we are offering a priority classification in which justice is used as the essential principle to which one appeals, with need and efficacy of treatment used to determine the terms under which patients are treated, where they are treated and when they are treated. Priority A defines those whose needs are deemed critical, whose condition is immediately life threatening, and for whom treatment is available. Their immediate need is greatest and we must find ways (either in the geographic area of the pandemic or elsewhere) where treatment can be instituted or continued.
practitioner, often with consultation, to fairly evaluate individual patients using the fundamental criteria of need and efficacy of treatment to categorize him or her as Priority A, B, or C. It is the ethical responsibility of the clinical subcommittee of the CCO Pandemic Planning Committee to fairly evaluate programs using these same criteria to determine their standings as Priority A, B, or C Appeals of decisions regarding prioritization of patients or programs will be decided by a local appeals committee made up of: the Medical Director, the relevant Program Director, a bioethicist if available, and others relevant to the particular decision. It is anticipated that each wave of the pandemic will occur in a particular geographic area so that other area cancer clinics and hospitals will be utilized for Priority A patients when necessary. In the event of a wide spread pandemic where this is not possible, the same criteria will be used to prioritize but even all Priority A patients may not receive prompt treatment.
Priority B defines those whose needs are deemed to be non-life threatening and for whom services can be deferred during a pandemic wave (6-8 weeks). Physicians will determine that these patients are not put at undue risk. If their priority changes they will be moved to priority A and treated at a cancer centre somewhere in the province or country. Priority C defines those for whom services may be discontinued for the duration of the pandemic. These patients are, for the most part, undergoing routine follow-up or screening and can reasonably wait until the pandemic is over. It is the ethical responsibility of the Chapter #17B: Cancer Care
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Table 17B.1: Cancer Patient Priority Classification Priority
Description
Examples
Priority A
Patients who are deemed critical and require services/treatment even in the event of a pandemic because their situation is immediately life threatening. The following is a list of situations in which patients need priority assessment. Such patients may need admission depending upon resources and the severity of the condition. The list is not limited to these situations. The important factor is that a patient has a condition that is potentially life-threatening.
• Spinal cord compression requiring emergency MRI and radiation oncology consultation and ongoing symptom management • Superior vena cava (SVC) syndrome, requiring radiation oncology consultation • Pathologic fractures of an anatomical location requiring orthopedic assessment regarding fracture stabilization, radiation oncology consultation, and ongoing pain management • Acute and massive GI bleed or hemoptysis – requiring aggressive analgesic and anxiolytic admission, possible investigation to identify source of bleeding, possible radiation oncology consultation depending on site and etiology of the bleed • New onset, acute delirium – probably requiring assessment of patient to determine etiology and appropriate treatment of delirium • Acute, new onset or progressive dyspnea – requiring assessment; depending on etiology and performance status, the patient may need radiation, thoracentesis, chest tube drainage, possibly pleurodesis, and possibly palliative chemotherapy, or, if intervention is not appropriate or possible, then symptomatic management of dyspnea will be needed • Malignant bowel obstruction or bowel perforation – requiring assessment and alleviation of acute symptoms, may need radiology services, and may need nasogastric tube (NGT) decompression of G-tube or surgical decompression • Septic shock • Metabolic crisis – hypo- and hypercalcemia • Acute pain crisis – requiring assessment to determine etiology of acute pain and initiate appropriate pain control measures • Rapidly progressing tumours such as brain, acute leukemia, aggressive lymphomas, and some head and neck cancers require assessment. Such patients may have priority for ambulatory radiation or chemotherapy if their cancer is potentially curable
Priority B
Patients who require services/treatment but whose situation is deemed non-life threatening; in the event of a pandemic, services/treatment could be discontinued for the period of the pandemic wave (6-8 weeks).
Within Priority B, sub-categories of patients will emerge – patients would receive services/treatment based on availability of resources and anticipated clinical outcomes (i.e., potential for cure adversely affected by delay in treatment; risk to patient if he or she develops influenza during treatment)
Priority C
Patients whose condition is deemed non-life threatening and for whom services can be discontinued for the duration of the pandemic.
• • • • •
Chapter #17B: Cancer Care
Ontario Breast Screening Program Familial oncology/genetics clinics Well follow-up clinics Non melanoma skin clinics Prevention clinics
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Clinical Program Criteria for Classifying Patient Needs 1) Screening Programs a) Ontario Breast Screening Program
Most Ontario Breast Screening Program (OBSP) clients can be deferred for the entire pandemic since screening activities for the healthy population would not be recommended while there is pandemic activity in the province. Only previously screened clients with highly suspicious findings or an abnormal screening result in mammography requiring assessment should be seen. The feasibility of an assessment during the 6–8 weeks of a pandemic wave will depend upon availability of resources. Priority A: There are no Priority A patients. Priority B: Patients already screened who have highly suspicious findings. Clients who have an abnormal screening result on mammography requiring assessment are unlikely to be seen until the pandemic wave is over, unless staffing is unaffected. Priority C: From the start of the pandemic, all booked screening clients. They do not need screening until the pandemic is over.
divided into 11 categories that are measured in 10% decremental stages (100% to 0%). These categories are organized into three stages: 1) Stable, 2) Transitional and 3) End-of-Life. The PPS provides a framework for measuring progressive decline over the course of illness. The ESAS is a valid and reliable selfassessment tool to assist in the assessment of nine common symptoms experienced by cancer patients. The tool is designed to assist in the assessment of: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. The severity at the time of assessment of each symptom is rated from 0 to 10 on a numerical scale, with 0 meaning that the symptom is absent and 10 that it is the worst possible severity. Selected ESAS scores such as pain, nausea and dyspnea can also be used to identify an oncology emergency that requires urgent attention. The PPS can be used to help identify which patients should be seen in a clinic or a home visit. When utilizing the ESAS and PPS tools, the emphasis may have to be on the change in a patient’s scores with time rather than the absolute scores. Priority A:
b) Familial Oncology / Genetics Clinics
Priority C: From the start of the pandemic, all familial oncology/genetics clinics. 2) Palliative Care Program The Palliative Performance Scale (PPS) and the Edmonton Symptom Assessment System (ESAS) will be used as a screening tool to classify patients into priorities A, B and C. The PPS is a reliable and valid tool used for palliative care patients. The PPS is
Chapter #17B: Cancer Care
• Emergent palliative care symptoms in high functioning patient (PPS >60–70).
• Any PPS score with an oncologic emergency
• Any selected ESAS >7/10 Priority B
• Moderate problems with pain management necessitating medication adjustment – minor to moderate dose adjustments or switching of opioids could be done by telephone
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communication by the MD or visiting RN (in consultation with the MD as necessary). Home visits or outpatient clinic appointments may be needed
• Ascites – managed in the home setting or outpatient clinic with the use of diuretics and possible paracentesis as needed. GI complaints such as nausea and constipation can be managed with telephone consultations most of the time (e.g., utilize CCO Telephone Nursing Practice and Symptom Management Guidelines). See: http://www.cancercare.on.ca/ NursingTelephonePracticeGuidelines.pdf.
• Anxiety and depression can initially be managed by a home assessment by visiting RN or by MD, and follow-ups thereafter can be done by phone. If concerned regarding the status of the patient, then the RN or MD will need to make another home visit
• Patients with bony metastases or possible pulmonary embolus/deep vein thrombosis (PE/DVT) based on clinical judgment alone and PPS <30 if ESAS scores <5
• Caregiver stress and burnout could be managed and facilitated through the use of hospice volunteers. Priority C: Palliative patients with ESAS scores <3 who are stable. 3) Radiation Treatment Program All Radiation Programs in Ontario have explicit or implicit prioritization and wait list management systems in place. These should be reviewed regularly, documented and discussed with local disease site teams. These have been developed due to the chronic shortfall in consultation and radiation planning and
Chapter #17B: Cancer Care
treatment capacity over many years. The efficacy of these systems is demonstrated by the Cancer Care Ontario internal wait time data and publicly posted wait times (see CCO website: http://www.cancercare.on.ca), which show that some types of cancer (such as head and neck, lung and GI) are treated sooner than others (such as adjuvant treatment for breast cancer). These prioritization and wait list management systems will be beneficial when dealing with capacity shortfalls during a pandemic. The local Radiation Program prioritization criteria, as well as the CCO Priority Categories (1, 2 and 3) would determine in which priority category (A, B or C) patients will be classified (see below) It should be possible to determine at the time of consultation whether the risks of the pandemic infection outweigh the risks of delaying treatment for that individual patient. It should be noted that a delay in instituting radiation treatment should be as short as possible and that evidence suggests that there is no safe delay period, so that the decision rests on an assessment of relative risks for an individual patient Patients on follow up should be grouped into low and high risk and the low risk patients rescheduled to an appointment after the pandemic is over. Priority A: CCO Priority Categories 1 and 2
• All emergency and urgent patients where alternative management to radiotherapy is not possible (e.g., patients with cord compression not amenable to surgery) would need to be treated, but patients with bone pain might be able to be managed temporarily with adjustments to pain medication
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• Patients with rapidly progressing, potentially curable tumours
• Patients already on treatment. For Priority A patients, there would need to be sufficient staff in all departments / professional groups (radiation oncologists, radiation therapists, medical physics, nursing and support staff) within the radiation program to achieve safe quality consultation, planning and treatment. Staff should not be pulled to work in other parts of the hospital. They are needed for Priority B as well as Priority A patients, because in principle we would want to treat as many patients as possible, as the outcome of patients with cancer will be affected by delays in treatment. Priority B: CCO Priority Category 3
• All other patients with cancer needing radiotherapy. Within this priority level, subcategories would be determined using the local priority methodology (as described above). Patients should be followed by telephone where possible to ensure they have not progressed to Priority A. Priority C: Includes the rare patient with benign disease needing radiation treatment, such as pituitary adenoma and meningioma. It may be possible to delay these cases until the pandemic is over. Referral information should be reviewed and a decision made as to whether their consultation can be delayed. Patients on follow up should be grouped into low risk and high risk, and the low risk patients rescheduled to an appointment after the pandemic is over. Telephone follow up for high risk cases should be utilized as far as possible. 4) Surgical Oncology Program
Overall criteria for surgical oncology
Chapter #17B: Cancer Care
priorities are: Priority A: Patients in whom a delay in surgery would result in either an immediate threat to life or limb, or would significantly alter the patient's prognosis (CCO Priority Categories 1 and 2, emergent and very aggressive tumours).
• Patients with obstructions, bleeding or perforations
• Slightly less urgent (B+) patients would be those with a narrow window of opportunity for definitive surgery, such as those who have been on neoadjuvant protocols. A significant delay for the neoadjuvant patients could negatively impact on their outcome by allowing for recovery of residual cancer and thus losing the benefit invested in the neoadjuvant approach. Management of a Priority A case would require preoperative laboratory work up and radiology services as well as medical consultation in some cases (e.g., cardiology and respiratory specialist availability). Surgery itself requires anesesthiology staff, surgeon and assistant, operating room nursing, pathology services, recovery room nursing, and inpatient care nursing. As Priority A patients will represent the sickest of our population, there will be requirements for ICU and step down care for post operative management of some of these patients. A functioning operating room will require some level of ongoing support from the hospital’s material management and services sections (sterilizing and processing instruments, etc.). Capacity to undertake care of Priority A patients may be severely limited due to lack of ICU and inpatient beds. Focus may be for life-threatening situations for patients with potentially
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curable cancers. Priority B: Individuals for whom a delay of a number of weeks would not be anticipated to have an impact on survival or outcome (CCO Priority Category 3).
• Most solid tumour cases (e.g., breast, colon, lung, genitourinary [GU], gynecological, head and neck, gastrointestinal [GI]) – provided delays were in the range of weeks. Priority B patients would have to be followed, as excessive delay, evidence of unexpected progression, or the onset of symptoms (e.g., bleeding, obstruction) would mandate reclassifying as Priority A. Priority C: People for whom a delay of months would be unlikely to affect outcome (CCO Priority Category 4).
• indolent tumours • well differentiated thyroid cancers, early prostate cancers and non melanoma skin cancers. The ability to undertake cancer surgery that requires inpatient care will depend on the availability of beds for surgical patients (many beds may be occupied by symptomatic influenza patients and few, if any, ICU beds available) as well as staff and support services to manage these patients. Wait lists will require regular review to determine priorities in light of bed and resource availability. In critical bed and resource situations, the surgical priority may need to be on lifesaving procedures for those patients whose long-term prognosis for survival from cancer is good. Outpatient cancer surgery for Priority A or B patients should be included in hospital plans, if resources are available. Chapter #17B: Cancer Care
Hospitals may plan to discontinue most outpatient surgery, as it is not urgent. 5) Systemic Therapy New patients who fall into Priority A should continue to be seen to determine if treatment is urgent/curative. Local disease site teams will determine which patients are deemed curative and/or urgent (CCO Priority Categories 1 and 2). New patients who fall into Priority B can be deferred for several weeks. A mechanism is required (e.g., by phone) to ascertain that new problems have not developed if the decision is not to treat urgently, and for patients to contact the treatment centre to be assessed if problems arise (CCO Priority Category 3). In situations where there are insufficient resources to treat all curative and/or urgent cases, patients with life-threatening symptoms who have potentially curable cancers will be given priority. Priority A: CCO Priority Categories 1 and 2)
• Those patients being treated who have aggressive tumours, e.g., some leukemias, lymphomas, tumours of the central nervous system, or transplant nd
• Patients with life-threatening situations, e.g., leukemic leucostasis, or medical emergencies such as febrile neutropenia and hypercalcemia
• Some patients already receiving treatment In situations where there are no hospital beds, ambulatory treatment strategies may be required in situations where inpatient care is the normal approach. Priority B: CCO Priority Category 3
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• The majority of patients requiring chemotherapy (who are not Priority A or C). Recognizing that there are little to no data supporting long delays, this will be a judgment call for each new patient
• Patients already receiving therapy will need to be assessed as to whether they require ongoing treatment (Priority A) or can possibly wait weeks before continuing treatment. Priority C
• Patients receiving oral hormone therapy, especially in the adjuvant setting
• Well follow-up patients • Patients on IV bisphosphonates, if that is the only IV treatment required. Unless there is a life-threatening situation, patients who exhibit influenza symptoms will not be treated with chemotherapy.
Criteria to determine whether a program/service should cease operating 1. Ontario Breast Screening Program Cancellation of all breast screening services, since screening is elective and targets well women. 2. Palliative Care Program The primary issue when planning for an influenza pandemic is the issue of human resource management. A screening tool would be required to triage patients by telephone. It would be important to identify which patients need to be seen and which patients could be managed via telephone. The telephone will have to be utilized more in the event of a flu pandemic.
Chapter #17B: Cancer Care
In the event of a flu pandemic resulting in limited resources (e.g., physicians, community nurses, and hospital beds), using unoccupied hospital outpatient clinic space (most ambulatory clinics will be closed during the pandemic wave) may have to be considered. This might help to ensure higher efficiency for staff, while utilizing fewer nurses and physicians. The clinic could be supplied with “holding beds” and nasogastric tubes, etc., for use until the patient is stabilized and sent back home. Patients with PPS>60% could be seen in the expanded clinic for assessment. For patients with PPS<50%, consider using symptom response kits in a somewhat expanded version. These would be equipped with the necessities to manage a pain crisis in the home (e.g., subcutaneous [sq] meds, nasogastric tube for bowel obstruction, expanded sq meds). Telephone triage could be used to determine if a home visit is necessary. 3. Radiation Treatment Program If there are insufficient staff in any department or professional group to ensure safe and quality planning and treatment, and if other professional groups are unable to cover this work, then that aspect of care would need to cease. Radiation planning and treatment is a multiple-step and complex process, so disruption of any aspect can cause complete cessation of care. Re-referral of patients to other centres may be an option, depending on the extent of the pandemic and regional access. 4. Surgical Oncology Program Purely elective procedures and screening procedures (elective screening endoscopy) should be put on hold. Examples of services that would be suspended are elective joint replacements, elective general surgery (non-incarcerated hernias,
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non-acute gallbladders), and cosmetic surgery. Essentially all non-urgent and non cancer surgery should come to a standstill until urgent and cancer cases are looked after, and the post pandemic cancer backlog is addressed.
cancer centre to determine priority A, B or C.
5. Systemic Therapy Program The program would cease to function if insufficient staff were available to ensure that all safety standards would be met.
Priority B patients should be contacted by an individual responsible for triage (preferably an oncologist or a nurse) to undertake a phone consultation and to explain process for appointments. Patients should be put onto a list and informed that they will be contacted again for an appointment. It will be necessary to verify referral information and provide the patient with a number to call if the clinical condition changes.
Cancer Program Operational Recommendations Symptomatic patients A process is necessary to determine whether patients booked for the next day’s clinic have ‘flu symptoms’ for which they will be advised to follow the hospital’s process for patients with respiratory symptoms. Patients with influenza will not attend a clinic. To protect staff and other patients, a protocol will be necessary for those patients attending a clinic who have respiratory symptoms thought to be cancer related or a treatment side effect, in case the patient does have influenza. Cancellations • Follow-up patients for visits greater than six months
• Non melanoma skin clinics • Familial oncology clinics • Prevention clinics • Program Priority C patients and OBSP clients. New patients A triage process for new patient referral is necessary. A process should be established to review referrals following their receipt at the Chapter #17B: Cancer Care
Priority A patients should be contacted with an appointment. If resources are not available, patients should be treated as per Priority B protocols.
Each centre should determine how the triage will work within their organization depending upon their available resources. Treatment patients Where possible, patients already on treatment should continue therapy. Patients in Priority A should be treated. Waiting lists should be created for Priority B patients requiring treatment. Patients should be contacted by a triage nurse to discuss the situation; treatment should be initiated as soon as feasible. As treatment slots become available, patients on the ‘waiting list’ should be contacted. Patients should be given a telephone number to call in the event that their condition changes. Discussion should occur with the patient regarding the balance between any delay in initiating treatment versus the adverse effect of contracting flu with risk of complications if the patient is immunocompromised by the therapy (especially chemotherapy).
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A cancer telehealth line A cancer telehealth line should be set up in each centre and staffed appropriately for patients to call if they have any questions.
a) patients with life-threatening and potentially curable cancers, and b) patients who have waited longer than 12 weeks for radiation or systemic therapy.
Patient communication It will be up to organizations to determine how they prefer to deliver a message to patients. It is suggested that there be direct communication to patients as well as a letter. It is recommended there be a phone call to patients conveying key messages. The individual handling triage should call the patients who have been waiting four weeks, and complete an assessment over the phone to determine whether it is appropriate to continue the wait for treatment. Key messages for patients
• Your referral has been received. • There is a process to triage referrals; you will be contacted with an appointment.
• You will be put on a waiting list. You will be assigned to a priority. [Note: It is not necessary to provide patients with too much detail regarding where they fit into the priority system; instead, inform patients that the priority is determined based on the safest approach for patients.]
• You should call us at X telephone number if your condition changes. Re-referral If there is a regional disparity in the impact of the pandemic on a cancer program’s ability to see and treat patients, a re-referral process is recommended. Cancer Care Ontario will establish a rereferral process for:
Chapter #17B: Cancer Care
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17C. Chronic Kidney Disease / Acute Kidney Injury
Contents
Clinical Care of Patients with Chronic Kidney Disease (CKD) and Acute Kidney Injury
During an Influenza Pandemic ............................................................................................................ 1 1. Objectives ----------------------------------------------------------------------------------------1 2. Planning Assumptions -----------------------------------------------------------------------1 3. Clinical Services --------------------------------------------------------------------------------2 4. Recommended Strategies --------------------------------------------------------------------3 5. Staffing/Human Resource Contingency Plans-----------------------------------------8 7. Next Steps ------------------------------------------------------------------------------------- 10 Appendix 1: Chronic Kidney Disease Model of Care.................................................................... 12 Appendix 2: Chronic Kidney Disease Program Modalities & Definitions .................................. 14
Ontario Health Plan for an Influenza Pandemic August 2008
17C. Clinical Care of Patients with Chronic Kidney Disease (CKD) and Acute Kidney Injury During an Influenza Pandemic
For patients with end-stage renal disease, renal dialysis treatments and kidney transplants are their only treatment options. Dialysis treatment can be either in the form of hemodialysis or peritoneal dialysis, depending on the patient’s clinical condition and choice.
• creation and maintenance of vascular
At any given time, approximately .07% of Ontarians – or over 8,503 people – are receiving dialysis and other treatments – including transplants – for chronic kidney disease (CKD) or acute kidney injury. According to the Canadian Institute for Health Information (CIHI) 2007 report, Treatment of End-Stage Organ Failure in Canada, 1996-2005, in 2005, 20.6% of all Ontario dialysis patients were receiving peritoneal dialysis and 79.4% were receiving hemodialysis. In the event of an influenza pandemic, these life-saving treatments must be maintained.
See Appendix 1 for a detailed description of the CKD Model of Care.
The Ministry of Health and Long-Term Care funds a coordinated, accessible, high quality and cost-efficient system of services for patients with CKD and acute kidney injury. Programs in Ontario are currently organized in a hub-and-spoke model that consists of 26 regional centres, 64 satellites, 7 Independent Health Facilities (IHF). Peritoneal dialysis services are also provided in partnership with Ontario’s 14 Community Care Access Centres and the long-term care sector. Ontario dialysis facilities practice in an interdisciplinary model of care and provide the following services:
• chronic renal disease management and education
• pre-dialysis education, including information about dialysis options
access for dialysis treatment
• patient dialysis training • dialysis treatments, either at home or in a facility, and follow-up care
• renal transplantation services.
1. Objectives The objectives of pandemic planning for clinical care of patients with CKD and acute kidney injury are:
• To maintain essential kidney treatment and services during a pandemic.
• To make the most effective use of limited human and other resources.
• To be transparent and accountable to the public.
2. Planning Assumptions Pandemic planning for kidney care and treatment is based on the following assumptions:
• These guidelines apply to patients with chronic kidney disease (CKD) and to patients who have acute kidney injury (i.e., abrupt, sustained decrease in kidney function) – with and without influenza – during an influenza pandemic.
• CKD patients who have influenza are at high risk for complications. It is essential to segregate patients with influenza-like illness (ILI) from patients without ILI symptoms and treat as quickly as possible. Patients
Chapter #17C: Chronic Kidney Disease/Acute Kidney Injury
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with ILI will continue to receive treatments for their CKD or kidney injury but will be cohorted/segregated appropriately (e.g., Independent Health Facilities may only dialyze nonILI patients because they do not have the capacity to segregate patients).
• Over the duration of the pandemic, 35% of staff – including clerical staff, aides, RNs, dialysis technicians, social workers, nephrologists and the leadership team – will have influenza or will not be able to work because of family responsibilities. There will be a peak loss of up to 20 to 25%.
• For general planning assumptions for an influenza pandemic, see OHPIP Chapter 3.
3. Clinical Services Table 17C.1 lists the clinical services provided by the province’s Regional Programs. Clinical decisions (e.g., where services will be provided and by whom) will be made locally by the Regional Program. See Appendix 2 for a description of these services.
Table 17C.1: Clinical Services Provided by Regional Programs Program 1. Acute Kidney Injury Program
2. Chronic Kidney Disease Program
Services • ICU services for previously healthy individuals who have abrupt sustained decrease in kidney function – see Table 17C.3 on RIFLE criteria • Continuous Renal Replacement Therapy (CRRT) – done in hospital by intensivists or nephrologists, depending on the program • Pre-dialysis and treatment options clinics • Nephrology clinics – chronic kidney disease management Level I Chronic Hemodialysis Level II Chronic Hemodialysis Level III Acute Hemodialysis Hemoperfusion services (where available) In-hospital peritoneal exchanges Follow-up clinics
3. In Centre Dialysis Program*
• • • • • •
4. Home Dialysis Program (including peritoneal dialysis done in long-term care homes)
Training • Home hemodialysis/daily or nocturnal • Continuous ambulatory peritoneal dialysis (CAPD) • Continuous cycler peritoneal dialysis (CCPD) Maintenance • CAPD • CCPD adult • CCPD pediatric • Home hemodialysis Home visits
5. Body Access Creation and Maintenance 6. Transplant Program**
• • • • • • • • •
Nursing visits (follow-up) Technician visits (equipment repair and maintenance) Central venous catheter insertions (permanent) Central venous catheter insertions (temporary) AV fistula/graft insertions PD catheter insertions Cadaver donor Living donor Those waiting for a transplant and those who have had transplants (post transplant clinics)
* Includes residents of long-term care home transported to the Centre for hemodialysis **Responsibility for transplant programs is shared between transplant centres and CKD programs.
Chapter #17C: Chronic Kidney Disease/Acute Kidney Injury
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4. Recommended Strategies To maintain essential programs and services during an influenza pandemic, CKD Regional Programs and practitioners may consider the following strategies: 1.
Prioritize patient needs/deferring non-essential services
2.
Organize/deliver services in different ways
3.
Develop human resource contingency plans
4.
Develop a decision-making process/agreements between centres and sites to provide mutual aid.
4.1 Prioritize Patient Needs and Services During an influenza pandemic, programs and sites may not have the capacity (i.e., people, equipment) to treat all patients according to current clinical treatment guidelines. In the event that treatment services must be altered, reduced or deferred, CKD Regional Programs should use a consistent approach to prioritizing patient needs and providing clinical services. These guidelines provide a priority classification system to help CKD Regional Programs identify priority needs and determine which patients are treated, where and when. The classification system is based on an ethical framework using the principles of critical care triage (Chapter 17) and ethical guidelines in Cancer Service Planning (Chapter 17A-19), including:
efficacy, some may receive comfort care rather than active treatment
• Treatment choices will take into account the patient’s prognosis and chance of survival. Stage of kidney disease or level of acute kidney injury is based on specific diagnostic measures, which are used to indicate disease progression from mild to severe, pre-dialysis to dialysis: Table 17C.2: Stages of Kidney Disease* Stage
Glomerular Filtration Rate
Stage 1
Kidney damage with normal or increased glomerular filtration rate (eGFR greater than or equal to 90 ml/min/1.73m2)
Stage 2
Kidney damage with mild decrease in GFR (eGFR 60-89 ml/min/1.73m2)
Stage 3
Moderate decrease in GFR (eGFR 30-59 ml/min/1.73m2)
Stage 4
Severe decrease in GFR (eGFR 15-29 ml/min/1.73m2)
Stage 5
Kidney Failure (eGFR less than 15 29 ml/min/1.73m2) or dialysis)
*Adapted from the American Journal of Kidney Disease 2002; 39 (2, Suppl.1) S46-S75. Table 17C.3: RIFLE (Risk, Injury, Failure, Loss and End-stage Kidney Disease Classification of Acute Kidney Injury Class
Serum creatinine x 1.5
<0.5 ml/kg/hour x 6 hours
Injury
Serum creatinine x 2
<0.5 ml/kg/hour x 12 hours
Failure
Serum creatinine x 3, or serum creatinine ≥ 350 micromol/L with an acute rise >44 micromol/L
<0.3 ml/kg/hour x 24 hours, or anuria x 12 hours
Loss
Persistent acute renal failure – complete loss of kidney function >4 weeks
Endstage kidney disease
End-stage kidney disease >3 months
on need (justice) on their stage of kidney disease (table 17C.2) or level of kidney injury (table 17C.3) and actual/projected treatment
Urine Output Criteria
Risk
• All patients will be treated fairly based • All patients will receive care but, based
Glomerular Filtration Rate
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Ontario Health Plan for an Influenza Pandemic August 2008 Priority Classifications
examples of the types of patients that would fall in each priority category.
Table 17C.4 describes the criteria for prioritizing patient need and gives
Table 17C.4: Criteria for Prioritizing Patient Needs Priority Priority A
Description Patients who are deemed critical, whose condition is immediately life threatening. Their immediate need is greatest and Regional Programs must find ways (either within the geographic area of the pandemic or elsewhere*) where treatment can be instituted or continued.
Examples Acute Kidney Injury Patients • Patients whose injury or kidney failure requires immediate treatment to avoid permanent loss of function. End Stage Renal Disease (ESRD) Patients • All ESRD patients who progress to Stage 5 and who require life sustaining treatments (i.e., chronic hemodialysis patients, peritoneal dialysis patients) • Any home hemo/PD patient whose dialysis access has failed, which, if not corrected, will prevent dialysis from being initiated. Creation of Body Access to Make Dialysis Possible • Urgent vascular access surgery patients. • Patients with urgent PD catheter issues. • Any dialysis access failing or in jeopardy. Transplant Patients • Stage 4 & 5 ESRD patients for whom a cadaveric kidney is available for transplant (depending on availability of OR space and staff). • Post-renal transplant patients with Stage 5 kidney disease who require renal replacement therapy • Any medically unstable kidney transplant patient requiring frequent medical review.
Priority B
Priority C
Patients whose condition is not deemed to be life threatening, for whom services can be deferred or discontinued over the course of a pandemic wave (6 to 8 weeks). Physicians will determine that these patients are not put at undue risk. If their situation changes they will be moved to priority A .
Progressive Renal Insufficiency (PRI)
Patients whose condition is deemed non-life threatening and for whom services can be discontinued for the duration of the pandemic. These patients are, for the most part, undergoing routine follow-up or screening and can reasonably wait until all waves of the pandemic are over (i.e., 6 to 18 months).
Ambulatory Clinics • Based on their clinical condition, all patients attending ambulatory care clinics, except transplant and PRI patients who have urgent needs. New installations for home hemodialysis
• PRI patients who require urgent clinic visits. Transplant Patients • Post-renal transplant patients who require urgent clinic visits. • Recently transplanted patients requiring ongoing monitoring to avoid organ rejection. Home Dialysis Program • Home hemodialysis and PD patients who are near the end of home training should complete training and be sent home.
Follow-up Clinics • Home Dialysis Clinic patients who do not fit priority A or B.
* It is anticipated that each wave of the pandemic will occur in a particular geographic area of the province so that clinics and hospitals in other parts of the province can be utilized for Priority A patients when necessary. In the event of a widespread pandemic where this is not possible, the same criteria will be used to prioritize, but not all Priority A patients may receive prompt treatment.
It is the ethical responsibility of the practitioner, often with consultation, to evaluate each individual patient fairly, using the fundamental criteria of need and
actual or projected efficacy of treatment, to categorize the patient as Priority A, B or C.
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Ontario Health Plan for an Influenza Pandemic August 2008 Deferring Services/Patient Care Processes
It is the responsibility of the CKD Regional Program leadership to evaluate the level of service its programs will be able to provide during a pandemic, using these same criteria to identify priority services and services that can be deferred, and to plan care delivery for patients within their jurisdiction, including patients in their partnered satellite sites. All programs will review patient care processes, and identify those that can be deferred either temporarily or for the duration of the pandemic (e.g., assessing feet, conducting audits). Appeals
Any patient or family appeals of decisions regarding prioritization should be referred to existing hospital review/ appeal committees or the hospital
ombudsman. Every effort should be made to ensure there is someone with expertise in renal care on the review committee. Consideration should be given to providing patient/family advocates. 4.2 Organizing/Delivering Services in Different Ways During an influenza pandemic, services for chronic kidney patients may be delayed or disrupted, patients may have to go to different sites for dialysis, and they may have to rely more on self-care. Programs should consider the following strategies for planning, organizing and delivering services during a pandemic, which are based on the WHO pandemic phases (See Chapter 2: Roles, Responsibilities and Frameworks for Decision-Making – for the WHO Pandemic Periods and Phases).
Table 17C5: Planning Activities for CKD Model of Care by Pandemic Phase Program
Actions During the Pandemic Alert Period (phases 3 to 5)
Actions During the Pandemic Period (phase 6)
1. Acute Kidney Injury
• Review chapter 17 on acute care, including critical care triage
• Implement plans in conjunction with critical care
2. Chronic Kidney Disease
• Develop a plan to decrease or suspend ambulatory care clinics • Identify one site within a given geographic area to act as an urgent clinic for Priority A patients • Identify medically unstable patients and develop a process to monitor them closely, identify urgent needs and manage medical complications • Develop a communication plan to keep patients and families informed • Develop self-care materials and tools for patients and families
3. In-Centre Dialysis
• Identify and train patients who could be managed using home PD or home hemodialysis during the course of a pandemic • Develop process to make it easier for hemodialysis patients to enter centre during a pandemic (e.g., ID cards, ID cards for escorts or other arrangements, such as wheelchairs if escorts not allowed) • Develop a process for assessing time and frequency of hemodialysis on a case-by-case basis, (e,g., based on clinical judgment), reduce
• Implement plans to decrease nonessential services • Send notice or letter to all patients informing them that scheduled appointments will be cancelled during the pandemic, and telling Priority A patients where to call for information and go for urgent care, if necessary • Distribute self-care materials for patients (e.g., diet) through the Kidney Foundation and the Regional Programs • Determine whether additional clinic hours may be required post-pandemic to deal with the backlog • Send notice or letter to all patients informing them how services will change during an influenza pandemic, where they should call for information and, if necessary, where they should go for care • Issue ID cards to all patients who require in-centre hemodialysis so they can enter the facility easily • Implement plan to manage off-unit patients
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Program
Actions During the Pandemic Alert Period (phases 3 to 5)
•
•
• • • •
•
•
• •
4. Home Dialysis
• • • • •
• •
5. Body Access Creation and Maintenance
•
• 6. Transplant Program
• •
the hours spent (e.g., 4 to 2 hours) or the frequency of dialysis (e.g., 3 to 2 times per week); use this information to identify operating hours and staffing required Develop plans to manage off-unit patients during a pandemic – given that capacity to provide off-unit hemodialysis may be impacted by in-unit activity and availability of nursing/medical/technical staff In the event of shortage of machine time, develop backup plan to initiate peritoneal dialysis in the event of a shortage of machine time or to open up a fourth (night time) shift for in-centre patients to increase capacity for hemodialysis Establish plan to maintain water treatment systems Develop plan to optimize machine maintenance and address any medical/machine issues Identify any reserve machines Identify medically unstable patients and develop a process to monitor them closely; identify urgent needs and manage medical complications Identify ways to cohort/separate patients with ILI if possible; if not possible, identify other ways to reduce exposure to ILI (e.g., having patients wear masks) Work with patient transportation services to develop contingency plan to ensure patient transportation to and from the centre – including transportation for residents of longterm care homes Develop a communication plan to keep patients and families informed Develop plans with dialysis suppliers to maintain ongoing supplies of equipment, solutions, medications, and consumables for current and prospective new patients Identify any additional support that home dialysis patients may need to remain at home and avoid unnecessary ER visits Work with CCACs to plan to maintain home hemodialysis and peritoneal dialysis services during a pandemic Work with long-term care homes to maintain dialysis services for residents Work with long-term care homes to develop a coordinated communication plan to keep residents and families informed Explore other options for dialysis, such as shifting from continuous cycling peritoneal dialysis (CCPD) to continuous ambulatory peritoneal dialysis (CAPD) Develop information and tools on self-care Develop plans with dialysis and pharmaceutical suppliers to maintain ongoing supplies of equipment, solutions, medications, and consumables Confirm OR/radiology/diagnostic imaging plans/availability to maintain urgent vascular access surgery and manage PD catheter complications Develop plans to address any complications related to maintaining body access Develop plan to maintain urgent transplant clinic Develop plan to screen urgent patients for ILI
Chapter #17C: Chronic Kidney Disease/Acute Kidney Injury
Actions During the Pandemic Period (phase 6) • Adjust doses of antivirals to compensate for the clearing of antivirals during dialysis
• Send information to patients telling them who to call if their condition worsens, and maintain communications throughout pandemic • Distribute information and tools to help patients with self-care • Maintain communication with CCACs and long-term care homes
• Implement plans • Provide information to patients about where to go with any access maintenance problems • Implement plans • Distribute information to patients • Schedule urgent transplant clinic at a
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Program
Infection Control
General
Actions During the Pandemic Alert Period (phases 3 to 5)
Actions During the Pandemic Period (phase 6)
• Confirm OR plan for renal transplantation • Develop process to make it easier for transplant patients to enter centre during a pandemic (e.g., ID cards) • Develop a communication plan to keep patients and families informed • Conduct an initial assessment of the department to identify specific infection control issues that may need to be addressed during a pandemic. Initial assessment should involve Medical Director, manager and infection control coordinator • Train staff in the appropriate use of personal protective equipment (PPE) • Consider patient flow • Maintain two metre separation • Define cohorting plans • Define appointments for patients (not to arrive prior to appointment time to prevent too many patients in waiting room at the same time) • Consider increase in housekeeping needs • Restrict access for family/support persons • Discuss transport issues – develop alternative if current transport not available • Establish communication protocols for regional programs so all sites have appropriate contact numbers and give patients a consistent message • Work with facilities to develop plans to screen patients for ILI, including concise, accurate screening tools are available that will allow rapid assessment • Develop workload measurement tools and reports • Confirm process for ordering/receiving lab reports during a pandemic • Confirm with pharmacy and labs how to maintain adequate supplies of immunosuppressants, other pharmaceuticals and solutions, and laboratory services. Review renal specific pharmacy needs and alert pharmacy to ensure adequate supply of pharmaceuticals and solutions
4.3 Managing In-Centre Dialysis Patients with Influenza
frequency determined by the transplant centre. Transplant patients would need to continue lab work to determine appropriate level of immunosuppression. • Plan for initial consult with infection control coordinator first week of outbreak and determine need for consultation as pandemic continues (i.e., twice a week) • Provide education pertaining to infection control to staff, patients and family/support persons • Ensure language is not a barrier in education (tools should provide picture and written information) • Review use of PPE • Reinforce hand hygiene
• Screen patients by phone for ILI before their appointment; if patient has ILI symptoms, review case with nephrologists and reschedule if possible • If, based on the patient’s condition, appointments can not be deferred, schedule appointments for patients with ILI symptoms at the end of the clinic day • Ask patients with ILI to wear a mask and assess them in a designated isolation room • Review diets with patients and reinforce how important it is to follow diets and take prescribed and overthe-counter drugs as directed • Maintain data and review statistical reports at end of phase 6
Patients should also be assessed at a designated location at the unit level before entering into the unit.
Assessment
During a pandemic, patients will be assessed for symptoms of ILI at the designated CKD entrance of the facility. Hemodialysis patients will be given priority for assessments (e.g., ID cards that identify as hemodialysis patients). All patients entering the facility will be asked to use alcohol-based hand rub. In addition, patients exhibiting signs or symptoms of ILI will don a mask.
Triaging/Cohorting
Ideally, ILI patients should be dialyzed in a separate room if possible. If this is not practical, patients may need to be dialyzed in an open concept unit environment, maintaining a minimum of 2 metre/6 feet between patients, and placing a portable plastic screen around each patient. Assuming up to one quarter of hemodialysis patients may have influenza at the peak of
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the pandemic wave, up to one quarter of the in-centre hemodialysis units will need to be turned into a modified segregated area. Staff will wear appropriate PPE (see chapter 7). Minimal supplies should be taken into the isolation zone of each unit.
require hemodialysis and peritoneal dialysis – requires highly specialized skills. To develop a staffing contingency plan:
• identify the skill sets needed in your area as part of hospital global competency planning (i.e., hemodialysis, peritoneal dialysis, general medicine, nursing, venapuncture). (See Chapter 8, competency-based approach to HHR planning).
Treatment with Antivirals
Ontario has stockpiled enough antivirals to treat 25% of the general population (or the proportion that is expected to require treatment). CKD and AKD patients with ILI will be treated with antivirals. However, because antivirals may be filtered out in the dialysis process, dosages may have to be adjusted for kidney failure patients. Treatment with Antibiotics
Patients will be treated with antibiotics when clinically indicated following usual practice. 4.4 Managing Home Dialysis Patients with Influenza Regional Programs should instruct patients undergoing home dialysis on what to do if they develop ILI, including:
Nursing • Assume that nurse-patient ratios will be altered during the pandemic and that the nursing aides, dialysis technicians and other nephrology RNs as well as members of the leadership team will/may be providing direct patient care in the hemodialysis areas.
• Maintain list of recently retired nurses willing to come back to assist in an emergency.
• If nursing staff on orientation are near the beginning of training they could return to their in-patient units; if they are near the end of their training they should be assigned to patients whose needs match their skills.
• Do not go to the hospital • If they can still do their own dialysis, they should contact Telehealth, their primary care provider or CCAC, and seek medical attention and antiviral treatment as soon as possible.
• If they are unable to do their own
• Consider allocating kidney research nurses and other nurses with nephrology knowledge/ experience for clinical support as appropriate.
• CKD nurses with specialized knowledge
dialysis, they should contact the home dialysis unit. Regional programs may also consider the need to educate or support local health care providers/facilities to ensure they understand the needs of CKD patients.
5.
Staffing/Human Resource Contingency Plans
and skills should not be redeployed to areas other than the Nephrology Program. Infection Control • Ensure that Nephrology Infection Control support is available.
Caring for people with kidney failure/disease – particularly those who
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Management/Educators/ Administrative Staff • Managers and educators should be available for unit operation support 24/7 during the pandemic. Plans should be developed and communicated to all
• Manager and educator of each unit could be “buddied” for day hours of operation (i.e., if one is off, the other covers.)
• After 1600 hrs, consider creating a rotating perpetual on-call calendar where there is either a manager or educator on from 1400-2400 and 2400-0800 for support to all units. Would require 2 staff per night, 7 nights per week. On weekends, on call schedule could be developed for days as well, requiring one person per Saturday and one per Sunday. Social Work • Focus on priority tasks, such as crisis intervention and adjustment counselling services for patients, critical incident/stress debriefing for team members, and distress support for families if decision is made to discontinue dialysis
Housekeeping • Develop plan to maintain strict cleaning standards during a pandemic
• Identify and educate other hospital housekeeping staff in cleaning protocols in a dialysis unit. Nephrologists • Develop a plan to maintain nephrology services during a pandemic
• Determine whether nephrologists primarily working in research could provide support to clinical areas
• Identify other physicians who may be able to provide service in a nephrology unit
• Develop mutual aid agreements with other nephrology programs
• Identify international medical graduates with training in nephrology. Nephrology Technical Services • Develop a plan to maintain dialysis related equipment and assign technical staff to emergency repairs as needed
• Develop reciprocal arrangements with other dialysis units to provide technical support
• Identify community resources that could assist and provide appropriate training.
• Explore the role vendors could play in
Dietitian • Develop plan to maintain dietitian services, as diet and fluid restriction will be important interventions if treatment regimens have to change
maintaining equipment.
• Identify community resources that could assist and provide appropriate training. Clerical and Support Staff • Redeploy some clerical staff with routine clerical skills if needed
• Redeploy dietitians, social workers, and pharmacists if necessary.
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Leadership Role Administrators/Educators should:
• use the incident management system described in Chapter 2, and integrate with the facility’s own Incident Management System (IMS) plan
• focus on coordination of activities • establish a routine reporting schedule • hold daily debriefing and planning sessions with the full team including all disciplines
• assign a manager/educator team to assume responsibility for each unit
• establish a plan to cover the responsibilities of absent managers and educators
• create and update a list of all non-hemo nephrology nursing skills.
5. Support for Staff During an influenza pandemic, health care workers are likely to be working extended or extra shifts in an environment with high levels of stress. As part of pandemic preparedness, CKD Regional Programs should identify psychosocial support services provided by their facilities that will help health care workers fulfill their responsibilities. In addition to the services provided by employee assistance programs, facilities may consider providing:
6. Equipment and Supply Needs Regional Programs are responsible for maintaining a four-week stockpile of infection control equipment and supplies. The Ministry of Health and Long-Term Care will maintain another four-week stockpile of infection prevention and control supplies that programs can access. Please refer to the Equipment and Supplies guidelines, Chapter 10. In addition, Regional Programs are responsible for planning to maintain dialysis supplies – including purchasing, storing and managing supplies – for both in-centre and home programs. Someone on the team should be assigned responsibility for identifying the essential types and quantities of supplies that will be required to support care for CKD, AKD and PD patients. As most Programs do not have a lot of storage space and currently use a just-intime approach to supplies management, they may have to negotiate with vendors to ensure an adequate source of dialysis supplies (e.g., four-week stockpile) during a pandemic.
7. Next Steps The working group will develop:
• a surveillance system to track daily dialysis capacity across the province and recommendations for mutual agreements to re-refer patients with potentially lifethreatening or rapidly progressing curable/manageable CKD to other regions
• regular daily debriefings for staff • access to counselling • advice about self-care • assistance with child care, elder care, pet care, meals and other home responsibilities.
• a guidance document for transplant programs
• a plan for biomedical nephrology technical support, including a list of technologies in use across the province
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(i.e., number and type of machines), the number of technicians, and their skills
• a plan to maintain paediatric nephrology services during a pandemic
• guidelines for segregating and cohorting ILI patients
• provincial guidelines for transporting patients to and from dialysis units
• a plan to ensure CCAC and long-term care home (LTCH) capacity to maintain dialysis services (i.e., home dialysis for CCAC clients and peritoneal dialysis for LTCH residents), and ongoing support for care in these sites from the Regional Programs during a pandemic, including guidelines for the management of clients/residents with ILI (to be developed collaboratively with CCACs and LTCHs)
• guidelines for decision-making and handling appeals at all sites that are part of the Regional Program
• information for pharmacists • self-care information for patients.
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Appendix 1: Chronic Kidney Disease Model of Care Regional Centre • the Hub of the network for a defined
• direct recipients of funding for CKD services; Regional Centre is responsible for the distribution of funds to their Satellites including funding for all new CKD programs.
geographic region
• provides administrative, programmatic and clinical expertise to support patients at all levels of care for the full continuum of care
• responsible, accountable and has authority for CKD care throughout its assigned catchment area, including the areas served by its satellite operations
The Regional Centres are responsible for providing a full range of services to patients with CKD including:
• clinics – pre-dialysis and treatment options, nephrology and follow-up
• home visits by nursing and technical personnel
• responsible for leading the organization and administration of the regional program, program development and strategic direction, implementation and coordination of CKD clinical care and provision of quality patient care
• maintenance of patients on PD • maintenance of patients on HD • vascular access support including vascular surgery and interventional radiology
• responsible for all planning within their region, including establishing processes for Triaging patients, and ensuring a triage function is in place
• responsible for overseeing the management of all levels of CKD patients and the coordination and integration of services within its network
• assumes responsibility for the direct care of any patient being treated within the region and must maintain the ability and capacity to meet fallback needs without delay (i.e., meet the needs of patients treated in satellites who require Regional Centre services)
• must have dedicated in-patient bed capacity and associated support services to support the complex clinical needs of the Regional Centre and its satellites
• maintains linkages with tertiary centres
• PD catheter insertion • Chronic and acute HD • Training for patients who wish to perform their own PD or HD
• Service availability 24 hours per day, seven days per week. If a Regional Centre cannot independently provide all of the services listed above, the Centre is responsible for ensuring access to these services for the region through negotiated agreements with other facilities that provide guaranteed access to services within 24 hours where appropriate (i.e., vascular access care, complex care), and within reasonable timelines for other services. The Regional Centre maintains a linkage with a tertiary health science centre for clinically complex patients.
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Satellites • have full affiliation with a regional centre
• Partnered with CKD programs in accordance with a Memorandum of Understanding with the partnered CKD Program
• provide hemodialysis (HD) treatment for chronic CKD patients within their geographic catchment area including stable and sometimes unstable patients
• responsible for leadership, program development, implementation and coordination of CKD care throughout their catchment area across the continuum of care
• Funding received from the Acute Hospital Replacement allocation budget.
Independent Health Facilities • Governed under separate statute, The independent Health Facilities Act Ontario, and accredited by the College of Physicians and Surgeons of Ontario
• multidisciplinary team associated with the Regional Centre oversees the care of patients receiving HD treatments at a satellite
• clear transfer protocols in place between the Regional Centre and the Satellite for transfer of dialysis patients, should the need arise
• Provide HD only to chronic stable patients.
Tertiary Centres • Participate as a specialized care provider in the regional service plan
•
• receive Ministry funding for CKD
treatment and access to a full continuum of nephrology care, including kidney transplant assessment and transplantation,
services from a Regional Centre.
chronic and acute dialysis treatment on an inpatient or outpatient basis for populations within their primary
Long-Term Care Home (LTCH) PD Satellite • Formal partnership between CKD Regional Programs and eligible LTC homes
Provide specialized diagnosis and
catchment area
•
• Provide PD only to residents of the
Share knowledge, expertise and research findings related to nephrology care.
LTCH
• CKD Programs responsible for coordination and support of in-centre hemodialysis provided for LTCH residents, PD services in designated LTC homes as well as ongoing monitoring and evaluation of performance.
CCACs • Provide support to PD clients in their home in accordance with PD care standards
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Appendix 2: Chronic Kidney Disease Program Modalities & Definitions Modality
Definition
Measured by:
Level I - Chronic Hemodialysis SATELLITES AND REGIONAL CENTRES
Hemodialysis treatment for stable chronic ESRD patients – self-care, assisted self-care or dependent full care. The interdisciplinary team hours may be variable, as they relate to patient acuity. The team hours per treatment will not exceed 2.25 hours. Staff:Patient Ratio is 1:4.
number of treatments (e.g. patient dialyzes between 3-5 hours per treatment)
Level II - Chronic Hemodialysis REGIONAL CENTRES ONLY
Hemodialysis treatment, performed in an acute care dialysis unit located in a hospital, for unstable, chronic and acute ESRD patients. The patients are of high acuity, may be unstable during the dialysis procedure and must be seen by a Nephrologist each visit. The interdisciplinary team hours may be variable, as they relate to patient acuity. The hours of care will be 2.26 to 3.25 hours. Staff:Patient Ratio 1:3.
number of treatments (e.g., patient dialyzes between 3-5 hours per treatment)
Level III - Acute Hemodialysis REGIONAL CENTRES ONLY
Hemodialysis treatment performed on acutely ill patients in-hospital in an acute care unit outside the dialysis unit (e.g., adult/paediatric intensive care unit, cardiac care unit, burn unit). The interdisciplinary team hours of care will be equal to or greater than 3.26 hours.
number of treatments
Hemoperfused REGIONAL CENTRES ONLY
This extracorporeal treatment is performed on acutely ill patients in an acute care unit such as intensive care unit and includes the use of a charcoal filter (such as those that are used to manage an overdose). Each treatment includes 1 filter per 4 hours of nursing time.
number of treatments
CRRT REGIONAL CENTRES ONLY
Continuous Renal Replacement Therapy (CRRT) is performed on acutely ill patients in an Acute Care Unit area such as Intensive Care. This code includes hemodialysis backup for the ICU staff for starts or restarts, as well as 1 filter per day.
number of treatment days
In-hospital Peritoneal Exchanges REGIONAL CENTRES ONLY
This includes manual peritoneal dialysis (PD) bag changes for patients on CAPD (continuous ambulatory peritoneal dialysis) for acutely ill patients performed inhospital. This also includes automated exchanges using a cycling device (CCPD) or continuous acute care cycling.
number of procedures (e.g., patient dialyzes between 4-5 times per day)
Training - Home/Self-care Hemodialysis Treatments
An intensive education period for the hemodialysis patient who subsequently will be able to manage his/her own treatment in the home/self-care unit. This period, which may include the training, takes a variable number of days (range of 18-24 treatment days), which includes the cost for hemodialysis treatment during the training period.
number of days trained
Training - CAPD
An intensive education session for a peritoneal dialysis patient undertaking to learn to manage personal peritoneal dialysis in the home. The training may or may not occur in a patient’s home. This training takes a variable number of days. Costing includes both training days as well as the Peritoneal Dialysis exchanges done during training. Average training time, including the initial home visit, typically varies from 4-8 days (average of 5 days).
number of days trained
Training -CCPD
An intensive education session for a peritoneal dialysis patient undertaking to learn to manage personal cycler peritoneal dialysis in the home. The training may or may not occur in a patient’s home. This training takes a variable number of days. Costing includes both training days as well as the peritoneal dialysis exchanges done during the training. Average training time, including the initial home visit, typically varies from 4-8 days (average of 5 days).
number of days trained
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Modality
Definition
Measured by:
Maintenance - CAPD
Continual ambulatory peritoneal dialysis is a type of peritoneal dialysis in which patients receive 4-5 peritoneal dialysis exchanges each day utilizing 2-3 litres of dialysate each exchange. This treatment may be carried out in a patient’s home. A night exchange device may be used to enable this patient to do 1 extra peritoneal dialysis exchange during the night.
number of annualized patients (e.g., patients on this treatment over a year)
Maintenance - CCPD Adult
In continual cycler peritoneal dialysis (CCPD) - Adult, a peritoneal dialysis patient utilizes a cycling machine to do several peritoneal dialysis exchanges, usually throughout the night. Such patients frequently do peritoneal dialysis exchanges during the day as well.
number of annualized patients (e.g., patients on this treatment over a year)
Maintenance - CCPD Child
In continual cycler peritoneal dialysis (child) a paediatric peritoneal dialysis patient utilizes a cycling machine to do several peritoneal dialysis exchanges throughout the night. Such patients may also do peritoneal dialysis exchanges during the day.
number of annualized patients (e.g., patients on this treatment over a year)
Maintenance - Home Hemodialysis
Hemodialysis treatments for the hemodialysis patients, usually performed three times per week in the homes. This is done by the patient or with the help of an unpaid trained assistant such as a family member. In some circumstances a paid trained assistant is required (currently the payer is either a private insurance plan or via the hospital concerned). If the patient is admitted to hospital, then he/she should not be counted as a home hemodialysis patient.
number of annualized patients (e.g., patients on this treatment over a year)
Home Visits - Nursing & Technician
Home or satellite unit visit of interdisciplinary team member (e.g., nursing, dietician, physiotherapist, etc.) or biomedical technical staff for the purpose of patient/equipment care and support. The time spent for each visit includes travelling time (to and from) and visiting time. Travelling time is dependent on where the home or the satellite is located. Visiting time is dependent on the purpose of the visit (i.e., follow-up visit/replacement and/or machine repair).
number of hours for each visit
Clinics - Pre-dialysis and Treatment Options
Interdisciplinary outpatient clinic dedicated to the assessment, medical management, treatment and support of patients with creatinine over 250 ummol/L. Education provided to families and patients regarding normal/abnormal renal function, renal failure, treatment options, nutrition, medications, and lifestyle and adjustment issues.
number of visits
Clinics - Nephrology
Outpatient clinic visit dedicated to the treatment of nephrological conditions for patients with creatinine less than 250 ummol/L.
number of visits
Clinics - Follow-Up Visits
Follow-up clinic visits are a clinical assessment of the patient having hemodialysis or peritoneal dialysis done at home, or at a satellite or an independent health facility which occurs under one of two circumstances: • Patient undergoes a multi-disciplinary team assessment as well as laboratory testing at the Regional Centre, • A multi-disciplinary team from the Regional Centre visits the satellite dialysis units to provide clinical assessment to a patient dialysing in that unit. The clinical assessment would include laboratory testing.
number of visits
Peritoneal Equilibrium Test CAPD/CCPD
A procedure involving a 4 hour peritoneal dialysis exchange done in the clinic under supervised conditions with sampling of blood and dialysate on a number of occasions during that 4 hour period. This should be done on all patients during or shortly after initial training and repeated when clinically indicated (e.g., 1 per year).
number of tests
Insertion -Vascular Graft Insertion
Surgically implanting a graft of synthetic material (between an artery and a vein) into a patient with end
number of procedures (e.g., one
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Modality
Definition
Measured by:
stage renal disease to be used for hemodialysis treatment.
procedure would be on insertion)
Insertion - Central Venous Catheter Temporary
Insertion of a temporary venous line into a patient with acute or chronic failure to be used for hemodialysis treatment.
number of procedures (e.g., one procedure would be on insertion)
Insertion - Central Venous Catheter Permanent
Insertion of a permanent catheter (i.e.: Perm Cath) into a patient with end stage renal disease to be used for long term hemodialysis treatment.
number of procedures (e.g., one procedure would be on insertion)
Insertion - AV Fistula
Surgical creation of an arterial-venous (AV) fistula into a patient with end stage renal disease to be used for hemodialysis access.
number of procedures (e.g., one procedure would be on insertion)
Insertion - Peritoneal Dialysis Catheter
Inserting a permanent catheter into a patient with end stage renal disease to be used for any form of peritoneal dialysis.
number of procedures (e.g., one procedure would be on insertion)
Chapter #17C: Chronic Kidney Disease/Acute Kidney Injury
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17D. Blood Services
Contents 1. Ontario Contingency Plan for Management of Blood Product Shortages .................................... 1 2. Contingency Plan Checklist for Hospitals ....................................................................................... 10 3. Notification of Blood Shortage – Amber Phase .............................................................................. 13 4. Notification of Blood Shortage – Red Phase.................................................................................... 14 5. Notification of Blood Shortage – Recovery Phase .......................................................................... 15 6. Slide Presentation ................................................................................................................................ 16
Ontario Health Plan for an Influenza Pandemic August 2008
17D. Ontario Contingency Plan for Management of Blood Product Shortages Ontario’s contingency plan for the management of blood product shortages was prepared by: Contingency Planning Working Group, a Working Group of the Ontario Blood Advisory Committee, Ontario Regional Blood Coordinating Network and Blood Programs Coordinating Office, Ministry of Health and Long-Term Care. The working group included transfusion medicine hospital personnel (both teaching and community), patients, Canadian Blood Services, Ontario Hospital Association and the Ontario Regional Blood Coordinating Network, and was formed to develop a framework contingency plan for hospitals. The plan is based on plans developed by the National Health Service in the United Kingdom, as well as the Nova Scotia Provincial contingency plan for blood component / blood product shortages. It is designed to be consistent with plans in other provinces so that the national blood supplier, Canadian Blood Services, can respond effectively to a blood shortage and not be restricted by provincial borders. Although the Ontario Contingency Plan for Management of Blood Shortages has been developed with blood components in mind (red blood cells, platelets, plasma), a similar approach can be taken to address shortages of plasma products (i.e. IVIG, albumin). Therefore, reference will be made to both blood components and blood products throughout the document.
Chapter #17D: Ontario Contingency Plan for Blood Shortages
Objective: To ensure secure access to safe blood products for patients who are most in need of them in times of critically low inventory levels.
Background In times of blood product shortages, a contingency plan must be in place to ensure that patients across the province have equitable access to essential blood products. The plan will help hospitals develop the communication and management strategies to respond to these situations, and will facilitate the overall reduction of blood product usage to ensure an available supply for the most urgent cases. The Canadian Blood Services has developed a plan to help manage the anticipated reduction to the blood supply during an influenza pandemic. Provincial blood programs must identify the actions to be taken within hospitals in the event of a severe and prolonged reduction to the blood supply.
Framework of Plan Categories or phases of shortages of blood products will be defined in a manner consistent with the Provincial Contingency Plan for Blood Component/Blood Product Shortages in Nova Scotia (see Table 17D.1)
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Table 17D.1: Phases of Blood Product Shortages Phase
Inventory Supply Level
Hospital Impact and Actions
Green
Normal operations
Inventory requests will be filled as per routine practice by the blood supplier. Hospitals can maintain inventory at optimum level. Hospitals should report hospital inventory to blood supplier on their product request form.
Amber
Short term shortage of inventory – may apply to a single blood group/ lot number, selected blood groups / lot numbers or to single blood product
Blood supplier will notify hospitals.
or
It is important for hospitals to share inventory levels with the blood supplier. The blood supplier requests that hospitals report their blood product inventory on the request order form.
Short term shortage of inventory may result from a large and unexpected need for products due to a local/regional disaster
Blood supplier may not stock orders to 100% of request. Urgent blood order requests will need to be triaged. Some activities in facilities may need to be reduced or delayed.
If shortage continues, Blood Supplier may progress to Red Phase. If inventory levels improve, Blood Supplier will move to Recovery Phase.
Red
A severe and prolonged shortage of blood components / blood products or If an imminent severe threat to the blood supply is identified (e.g., 30% loss of donations)
Blood supplier will notify all hospitals. Hospital order fill rates will be reduced by defined levels. Hospitals will need to have a defined internal plan to respond to such a request for reduction in blood usage. It is critical in this phase that all hospitals report their blood product inventory levels with blood supplier. This should be done directly on the blood product order request form and submitted with each request for product. All urgent blood order requests will need to be triaged (prioritization of need). It may be necessary to transfer blood products between facilities.
Recovery
Blood supplier will notify hospitals when inventories have returned to normal. Hospitals will raise blood usage / activity slowly and increase inventory levels gradually.
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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Actions Required by Phase of Blood Product Shortage Green Phase: Normal Levels of Activity and Requests for Blood Products Blood supplier inventory levels are at optimal levels and blood collection activity meets expected hospital demand. National blood supplier will develop communication strategies and plans to inform hospital Transfusion Services when inventory levels drop below desired levels. Inventory levels are defined for Amber phase and Red phase. These are communicated to hospital Transfusion Services. The corresponding request for reduction of blood orders must also be defined in the plan and this must be communicated to hospital Transfusion Services. The blood supplier will develop and communicate a plan to notify hospital Transfusion Services when inventory levels begin to recover and then again when inventory levels are stable. Hospital plans should indicate that normal operations/activity should resume gradually until blood supplier notifies a return to stable inventory levels to ensure that inventory stocks at hospitals return to normal levels in an equitable and stable manner. Hospitals should define the required inventory to be held on site to ensure normal blood demand will be filled, allowing for some unexpected emergency needs. These maximum/ minimum blood inventory levels should be determined based on historical blood product/ component usage, services provided at the facility, and physical distance from the blood supplier. Hospitals should define inventory levels to be consistent with the blood supplier. Canadian Blood Services
defines inventory levels by ‘average daily use’. Ideal inventory levels are 4 days or higher, critical inventory levels are defined as less than a 2 day level. Consideration should be given to defining red cell inventory levels to match contingency plan ‘phases’. For example:
• Green phase = 100% of optimal inventory or 4-6 days of average daily use
• Amber phase = less than 50% of optimal inventory or < 2 days
• Red phase = less than 25% of optimal inventory or < 1 day of average use Consideration should be given to the availability and dependability of existing transport routes and the probability of unexpected emergent patient needs (e.g., trauma, obstetrical). Hospital inventory levels should balance out to minimize the amount of discarded products. Where feasible, product redistribution between facilities should occur to maintain a balance between the amount of inventory held at each site and the inventory that becomes outdated and is discarded. Agreements should be developed between facilities located in proximity to share blood products should it become necessary. These agreements should outline the policies and procedures for the transfer of blood products and ensure that they maintain blood products in appropriate storage conditions with appropriate documentation. Hospitals should be managing blood use efficiently to ensure blood products are not ordered/transfused where not indicated. The use of existing blood product use guidelines, Maximum Surgical Blood Ordering Schedule (MSBOS), blood conservation strategies and regular auditing of blood ordering
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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practices will help to improve blood utilization. Understanding current blood usage figures according to surgical procedure will help determine the actions required to respond to requests for reduction of blood use. In addition, the adoption of a massive blood transfusion policy/ algorithm will help manage situations where large blood loss and blood needs may exist. During the Green phase, hospital Transfusion Services should facilitate the development of an internal emergency blood management plan (EBMP) to address blood shortages. Strategies must be identified to respond to a request for reduction of blood product/blood component use in times of critical inventory levels. This plan should be agreed to by all services/stakeholders requiring blood product/component support within the facility. This plan must be communicated throughout the facility to ensure that should the need arise, hospital personnel will respond in a coordinated manner to a request for reduction of the use of blood products/components. Each facility should form a committee or make use of an existing committee (such as the Transfusion Committee) to develop an emergency blood management plan during a critical blood shortage. The plan should:
• include personnel within the facility who must be notified of a situation of blood shortage and also a defined personnel fan-out
• include a communication strategy to notify patients and their families who may be affected by the reduced blood inventory
• be incorporated into the overall facility Emergency or Disaster plan
• have defined notifications and actions for both Amber and Red phases of inventory shortages
• define and document responsibilities and actions required by key individuals. Strategies for reduction of blood usage must be defined. These may include:
• reducing stock held on site to minimum levels
• adhering strictly to widely accepted transfusion triggers
• reducing the number of products given per treatment (e.g., number of platelet units)
• delaying or cancelling non-urgent elective surgeries
• categorizing patients to set priorities for blood product needs (i.e., lifethreatening to urgent to supportive to elective needs). Amber Phase: Short Term Shortage of Inventory May Apply to a Single Blood Group or Blood Product/Component The blood supplier will have defined inventory levels to determine when the Amber phase is initiated. The Blood Centre will notify all hospitals that it supplies via the Transfusion Service when an Amber phase of the emergency plan is initiated. This notification will occur by fax. The notification should include the nature of the shortage and anticipated timeframe for inventory to return to normal levels. The blood supplier will co-ordinate and oversee all media announcements regarding the blood supply and any call for donations should they deem this necessary and appropriate.
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When the hospital receives the fax notification that Amber Phase has been initiated, the Transfusion Service Medical Director or Consultant on call must be notified. The hospital will activate the Emergency Blood Management Plan for Amber phase. This may include:
• notifying administrative, medical and nursing staff of the situation
• reducing minimum inventory levels of affected blood group or blood product/ component
• triaging blood order requests between the Medical Director/Consultant of the Blood Centre and the Medical Director/Consultant of the hospital Transfusion Service to ensure patients in the most urgent need of blood products will receive them (based on transfusion triggers, clinical urgency of need, existing blood inventory levels)
• transferring blood products between sites to meet urgent patient needs
• delaying elective activities and nonurgent transfusions. Patients and their families must be notified if treatment with blood products/blood components is to be deferred. The reason for deferring treatment must be included in the communication.
“In some shortage scenarios this reduction in hospital stockholding may be sufficient to allow recovery from shortage. However, in most scenarios this will need to be accompanied by a reduction in blood usage by hospitals.” Emergency planning – development of an integrated plan for the management of blood shortages. NHS DoH Gateway Ref 3344. 23 July 2004.
The blood supplier will communicate regularly with hospital Transfusion Services – medical and technical staff – using defined protocols to provide status reports on inventory levels and anticipated recovery time or whether the inventory is dropping to even more critical levels. Once the inventory has returned to normal desired levels (Green Phase), the blood supplier will notify all hospital Transfusion Services via fax. Recovery of hospital blood inventory and return to normal activities (transfusions) should be slow and gradual to ensure the overall blood inventory level does not return to shortage levels. Red Phase: Severe and Prolonged Shortage of Inventory If inventory levels cannot recover in the short term, the blood supplier may notify hospitals of a move from the Amber phase to the Red phase. If an imminent threat to or precipitous drop in the blood supply is identified, the blood supplier may move directly from the Green phase to the Red phase. The Blood Centres will notify hospitals of the initiation of a Red phase via fax to hospital Transfusion Services. There may also be public service announcements. The blood supplier will co-ordinate and oversee all media announcements regarding the blood supply and any call for donations as necessary and appropriate. The blood supplier will reduce fill rates by a defined percent. This may be from 10% to 50% or more, depending on the severity and anticipated length of time of the shortage. When a hospital receives fax notification of a Red phase, the Transfusion Service Medical Director/Consultant on call must
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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be notified. The hospital will activate the Emergency Blood Management Plan for Red Phase. This should include:
• notifying senior administrative, medical and nursing staff of the situation
• reducing critical inventory levels of affected blood group or blood product/component
• triaging all requests for blood products/components according to defined criteria, and as required by the assigned medical staff (based on transfusion triggers, clinical urgency of need, existing blood inventory levels). Communication between the Medical Director/Consultant of the Blood Centre and the Medical Director/Consultant of the hospital Transfusion Service is necessary to ensure patients in the most urgent need of blood products receive them
• transferring blood products between sites to ensure the most urgent patient needs are met
• delaying elective activities and nonurgent transfusions. Patients and their families must be notified if treatment with blood products/blood components is to be deferred. The reason for deferring treatment must be included in the communication. The blood supplier will communicate regularly with hospital Transfusion Services – medical and technical staff – using defined protocols to provide status reports of inventory levels and anticipated recovery time, or if the inventory is dropping to even more critical levels. Once the inventory has returned to improved levels (Amber or Green Phase), the blood supplier will notify all hospital Transfusion Services via fax.
Recovery of hospital blood inventory and return to normal activities (transfusions) should be slow and gradual to ensure the overall blood inventory level does not return to shortage levels. Prioritization of need will continue until inventory levels are maintained, and activities and usage return to normal. Responsibility for this decision should be defined in the EBMP. The scheduling of elective procedures should be gradual, as the blood inventory levels may be vulnerable to returning to shortage during the recovery period.
Development of a Hospital Emergency Blood Management Plan This plan should be developed during the Green phase so that it will be available to implement in response should an event occur that would result in a shortage of blood products or components. Usually, the Transfusion Service personnel and Medical Director will respond to minor shortages in the supply of one or more blood groups and/or blood products by triaging blood order requests as they are received. Often, there is no coordinated approach taken outside of the Transfusion Service. Should a larger scale or prolonged shortage of blood products exist, this response would fail to reduce blood usage to the degree required. Severe shortages of the blood supply (either current or imminent) must be communicated to professional staff outside of the Transfusion Service to ensure that a multidisciplinary and cocoordinated response to a reduction of blood product use is achieved. This communication will enable those providing healthcare in the facility to prioritize the needs for blood products so that the limited supply of blood products will go to those patients in the most
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urgent need. All hospitals in a region/province need to have a consistent approach to ensure that equitable access to this critical supply will exist. All key stakeholders should be represented on the committee assigned to develop the hospital Emergency Blood Management Plan, including:
• transfusion service medical director/consultant
• consultant anesthetist • consultant surgeon(s) • hematologist/oncologist • chair of transfusion committee • manager responsible for transfusion service
surgical, nursing and senior administrative personnel should the need arise to delay or cancel elective procedures that might require blood transfusion; Red phase would need to include all of those mentioned above, in addition to the CEO and all senior medical and nursing staff. A mechanism is needed to define:
• categories of patients to prioritize for need for blood products
• how to safely implement blood conservation and transfusion alternatives to avoid anemia and reduce demand for blood
• how to triage blood order requests (e.g., pre-defined criteria, use of patient categories, direct medical approval)
• transfusion nursing specialist
• how to monitor blood use
• consultant from er/trauma
• daily monitoring of inventory levels
• board member/lay person • risk manager. This broad representation will result in joint decision-making on the strategies required to reduce blood usage at the facility and a collaborative response, should it be necessary to implement the plan. The plan should define personnel to be notified for various phases of inventory shortages. For example, Amber phase may initially include the Transfusion Service medical director, hematology/oncology and chief of intensive care and emergency, but may expand to chief of medicine and
and status of situation from blood supplier, and communicating this information throughout the facility
• how to coordinate surgical schedules relating to deferral of procedures
• how to prioritize patients/procedures during the recovery phase to ensure any inventory recovery can be sustained.
Types of shortages The types of shortages that blood centres may experience will vary based on cause of the shortage. An influenza pandemic is likely to cause a prolonged shortage (see Table 17D.2).
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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Table 17D.2: Types of Blood Product Shortages, Their Causes and Impact Type of Shortage
Possible Causes
Impact
Short Term Regional Shortages
Events affecting one blood centre, such as: inclement weather impacting donor clinics, facility failure affecting blood collection/processing, labour disruption affecting operations, a local disaster or terrorist attack
Short-term gap between demand and supply
Short Term National Shortages
Events affecting more than one blood centre or a very large blood centre that could result in a national reduction to the blood supply, such as: major labor disruption, information system failure affecting testing or traceability of blood products, or transportation chain failure
Short-term gap between demand and supply
Prolonged Shortage
Events affecting more than one blood centre, such as a change to donor deferral policy affecting large proportion of blood donors, pandemic flu or other illness resulting in a severe reduction in donor attendance and/ or blood centre personnel, failure of contracted manufacturing supplier (e.g., plasma protein product, or blood collection / processing / testing supplies), or a protracted labour disruption
Longer-term, severe discrepancy between demand and supply
Conclusion In the event a blood product shortage occurs, hospital Transfusion Services will be notified by the regional Blood Centre. Once this notification occurs, hospitals will take actions based on the severity and anticipated time frame of the blood product shortage. Actions may include reducing the inventory held on site and, if necessary, reducing the use of blood products.
manage and recover from a severe shortage of blood product/components, should one occur. References Better Blood Transfusion – Appropriate use of blood Health Service Circular HSC 2002/2009, Department of Health 04 July 2002. Emergency planning – development of an integrated plan for the management of blood shortages. NHS Gateway Ref 3344, Department of Health 23 July
Any reduction to the provision of blood products or components within a hospital must follow an Emergency Blood Management Plan developed internally by key stakeholders. This will ensure that strategies used to reduce service or prioritize patients will be accepted and followed. This, in turn, will help ensure equitable utilization of the limited inventory available across the region/province/country so patients whose need is most urgent will receive the blood products they require.
2004.
A more consistent approach taken by hospitals across the country will help the national blood suppliers – the Canadian Blood Services and Hema-Quebec –
Health and Nova Scotia Provincial Blood
Development of an integrated blood shortage plan for the National blood service and hospitals. NHS and NBS Chief Medical Officer’s National Blood Transfusion Committee Dec 2004. An integrated plan for the National blood service and hospitals to address Platelet shortages. NHS and NBS Chief Medical Officer’s National Blood Transfusion Committee. Gateway Reference 6514 06 Sept 2006. Provincial Contingency plan for blood component / blood product shortages in Nova Scotia. Nova Scotia Coordinating Program. Draft 4 04/06. How do I manage a blood shortage in a transfusion service? Transfusion 2007;47:760-762.
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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Communication and inventory management during
AABB Technical Manual 15th edition – Chapter 2
Pandemic influenza: Information for hospitals.
Facilities and Safety. Brecher M Ed AABB Bethesda
Canadian Blood Services Draft 4 2006-12-01.
MD 2005:p67-68.
(confidential document not for distribution) Transfusion Medicine Committee comments – TMED 0603 PP Questionnaire on disaster planning. QMPLS 2006-08-24.
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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Appendix A: Contingency Plan Checklist for Hospitals Preparedness for Responding to Blood Inventory Shortages Green Phase: Step 1 Inventory levels can be maintained at optimal levels
Establish Emergency Blood Management Committee (EBMC).
Ensure that ‘best practices’ in inventory management of blood components and blood products are in place.
Determine and make available ideal “on hand” inventory levels, indicating the number of days on hand represented by levels (ideal 4-6 days of average use based on historical data).
Practice routine strategies to ensure blood component/product outdating is minimized.
Adopt guidelines for the use of blood products to ensure effective utilization (through Transfusion Medicine Committee or Medical Advisory Committee).
Develop Hospital Contingency Plan for managing blood shortages. Ensure Emergency Blood Management Plan is integrated into Facility Disaster Plan. Provide training on the contents of the plan and the communication strategy related to blood shortages.
Establish relationships with other nearby facilities and develop a plan to share inventory in the event of a shortage.
(e.g., Maximum Surgical Blood Order Schedule (MSBOS) and/or protocol for review of blood ordering practice by physicians using ‘Best Practice’ parameters)
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Amber Phase: Step 2 Shortage not anticipated to be long term or severe. Shortage may affect only one or a few facilities if due to local or regional disaster
Ensure that Regional CBS Blood Centre will be notified of a local situation that could affect blood supply (e.g., equipment failure or multiple traumas).
Define response to notification of a blood shortage if received from CBS.
Develop communication template and list of contact names/numbers of those to be notified in Amber phase (include pager numbers, fax numbers, email addresses).
Prepare a communication to notify patients and their families to explain the need for possible deferral of their treatment, should it be necessary.
Ensure that contact information for other nearby sites is available if a need is identified for interhospital transfer of blood components/products. (List of available transport options with contact numbers should be available).
Give direction, in the plan, to reduce red cell stock (if shortage applies to this component) by 25% (3 day vs 4 day levels), and reinforce NOT to stockpile inventory.
Identify one person to act as a main contact with CBS to communicate any inventory needs and status of inventory at the Blood Centre, and to attend regular conference calls held by CBS, providing updates on the inventory status. This person/position should be determined beforehand, and his/her role should be documented to ensure everyone understands who is responsible.
If necessary, institute pre-approval of requests for blood components prior to releasing. The person/position assigned to perform pre-approvals, and what criteria will be used, should be determined beforehand.
If a situation appears to be worsening, notify the Medical Director of Transfusion Service and Chairperson of Transfusion Committee to determine if additional communication and/or actions are required to further conserve use of existing blood inventory: • Pre-approved contact list and communication template should be available • Prioritization list of areas where reduction of blood use will occur
Include notification to internal personnel including Transfusion Manager, Medical Director, Chair of Transfusion Medicine Committee, Chair of EBMC and other staff.
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Red Phase: Step 3 Inventory shortage predicted to be long term and/or severe
Notification of this level of shortage should be received from CBS.
Communication should include modification to ordering practices to be used, in order to conserve blood component inventory to ensure availability of product to treat urgent life-threatening situations. The Medical Director of the Transfusion Service or delegate shall review all orders that fall outside these parameters.
Reduce blood component stock kept on hand to minimum levels (1-2 days equivalent based on historical use).
Do not issue blood to ‘stock’ fridges such as operating room or trauma room.
Direction to work with local CBS Medical Director to determine priority inventory needs in region should be included in the plan.
Internal hospital notification should go out (in writing) to Division Chiefs of Surgery, Anesthesia, Critical Care, Trauma/Emergency, Hematology and Medicine, Directors of Laboratory Services, Diagnostic Services and Nursing, Chair of the Transfusion Medicine Committee (or its equivalent) and Emergency Blood Management Committee members. • Pre-approved contact list and communication template should be available • EBMC members should be identified; contact list should be available
DO NOT stockpile product to safeguard local needs, as this will result in increasing the overall risk to patients at other institutions.
Recovery Phase: Following notification from the blood supplier, CBS, by teleconference, that inventory levels are on the rise, hospital blood usage must remain restricted to critical needs, or increase at a controlled pace, in order to ensure levels do not result in a shortage in the Recovery Phase.
Notification of recovery of blood inventory stocks should be sent, in writing, to Division Chiefs of Surgery, Anesthesia, Critical care, Trauma/Emergency, Hematology and Medicine, Directors of Laboratory Services, Diagnostic Services and Nursing, Chair of the Transfusion Medicine Committee (or its equivalent) and Emergency Blood Management Committee members.
Communication template, approved distribution list and contact information should be available. Requests for blood components/products shall continue to be monitored and reviewed until CBS has notified the hospital of a return to the Green Phase.
References 1. Managing Potential Blood Supply Shortage. HEMA-BTL-PRO-A-PR01. Procedure from London Laboratory Services Group, London, ON. 2. Contingency Plan For Blood Component Shortages. DRAFT procedure Sunnybrook Health Sciences Centre, Toronto, ON. 3. Blood Shortage Policies. QM-TM-410A-01. Procedure from Cambridge Hospital, Cambridge, ON.
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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Notification of Blood Component/ Blood Product Shortage
Hospital Name Here
Memo To:
[Enter name of Chiefs of Surgery, Anaesthesia, Critical Care, Trauma, Emergency, Hematology, Medicine, Directors of Laboratories, Nursing and Risk Management, Chairpersons of Transfusion Committee, Emergency Blood Management Committee]
From: [Enter name of Medical Director of Transfusion Service] CC:
[Enter name of Transfusion service Manager / supervisor]
Date: [Enter date] Re:
Notification of Blood Shortage – *Amber phase*
We have received recent notification from the Canadian Blood Services (CBS) that they are currently experiencing a shortage of [Enter name of blood component / product here]. The shortage is the result of [Enter the reason for the shortage here]. As a result, blood inventory levels may be reduced in order to conserve product for critical cases. The following modifications to blood ordering will be implemented: !
ordering of the product in short supply will comply to ordering parameters as defined in the attachment provided with this communication
!
inventory levels for this product will be reduced by up to 50% in efforts to conserve
!
it may be necessary to consider deferral of elective transfusions and/or of elective surgical procedures associated with probable blood use
Note: This shortage is expected to remain for [Enter the expected time frame for shortage]. Until you receive further notification, you will be asked to follow the hospital procedure for Emergency Management of Blood – Amber Phase. Once inventory levels have stabilized, you will receive further notification of entry into recovery phase procedures. Should you experience a need for support in managing patients requiring blood during this period, please contact the Transfusion Service at [Enter the contact number desired].
Chapter #17D: Ontario Contingency Plan for Blood Shortages
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***Urgent Notification Of Blood Component/Blood Product Shortage
Hospital Name Here
Memo To:
[Enter name of Chiefs of Surgery, Anaesthesia, Critical Care, Trauma, Emergency, Hematology, Medicine, Directors of Laboratories, Nursing and Risk Management, Chairpersons of Transfusion Committee, Emergency Blood Management Committee, CEO, Public affairs / Communications]
From: [Enter name of Medical Director of Transfusion Service] CC:
[Enter name of Transfusion service Manager / supervisor]
Date: [Enter date] Re:
Critical Blood Shortage ** Red phase **
We have received recent notification from Canadian Blood Services (CBS) that they are currently experiencing a severe shortage of [ Enter name of blood component / product here] . The shortage is the result of [Enter the reason for the shortage here]. This shortage is anticipated to last for a prolonged period of time. As a result, blood inventory levels will be reduced in order to conserve product for critical and life-threatening cases only. The following modifications to blood ordering will be implemented: !
ordering of the product in short supply will comply to ordering parameters as defined in the attachment provided with this communication
!
inventory levels for this product will be reduced to a minimum (25-30%) in efforts to conserve product
!
it will be necessary to defer elective transfusion procedures and/or elective surgical procedures associated with probable blood use where patient safety will not be adversely affected
Note: This shortage is being experienced across the country and it could possibly continue for a prolonged period of time. You will be asked to strictly follow the hospital procedure for Emergency Management of Blood – Red Phase.
Communication will be ongoing with Canadian Blood Services.
Once CBS
inventories regain stability, you will receive further notification indicating when normal blood ordering practice may be resumed. Should you experience need for support in managing patients requiring blood during this period, please contact the Transfusion Service at [Enter the contact number desired].
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Notification Regarding Blood Component/Blood Product Shortage Situation
Hospital Name Here
Memo To:
[Enter name of Chiefs of Surgery, Anaesthesia, Critical Care, Trauma, Emergency, Hematology, Medicine, Directors of Laboratories, Nursing and Risk Management, Chairpersons of Transfusion Committee, Emergency Blood Management Committee]
From: [Enter name of Medical Director of Transfusion Service] CC:
[Enter name of Transfusion service Manager / supervisor]
Date: [Enter date] Re:
Notification of Blood Shortage – *Recovery Phase*
We have received recent notification from Canadian Blood Services (CBS) that inventory levels for [Enter name of blood component / product here] have steadily improved over the last week and have now reached a stable level. As a result, critical blood product conservation strategies may be lessened. Inventory levels on site will improve over the next few days back up to optimal levels. !
Elective transfusions and elective surgical procedures deferred as a result of the blood inventory shortage may begin to be recalled in a controlled and gradual way in order to reduce the possibility of de-stabilizing the recovery of blood inventory levels.
Note: We would like to take this opportunity to thank you for your support and collaboration during this difficult period. By working together, it was possible to use available blood inventory effectively to ensure the patients in most critical need received required products. Should you experience the need for support in managing patients requiring blood during this recovery period or if you have any questions/comments regarding this recent shortage and how it was managed, please contact the Manager of Transfusion Services at [Enter the contact number desired].
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18. Paediatric Services Even before the epidemic ended, New York City Health Commissioner Royal Copeland estimated that twenty-one thousand children in the city had been made orphans by the epidemic. He had no estimate of the number of children who lost only one parent. The Great Influenza, John M. Barry
Health care providers and organizations caring for children during an influenza pandemic will face unique issues and challenges. This chapter looks specifically at the needs of children and the health care settings that care for them.
18.1 Objectives • To highlight issues for health care settings caring for children during an influenza pandemic.
• To identify possible strategies to meet the needs of children.
18.2 Factors Affecting Paediatric Care during a Pandemic Children are at greater risk of infection from influenza, and of spreading the virus Children in school or daycare are more likely to become ill with influenza. Healthy children who are younger than 5 years of age are known to have excess rates of hospitalizations due to influenza illness. Among these children, those less than 2 years of age are at the highest risk. Rates of hospitalizations and morbidity due to influenza complications are known to be even greater among children with underlying chronic medical conditions (e.g., asthma, malignancies). Because children shed the greatest amount of virus for the longest period of time, require more “hands-on” contact, and are less able to comply with infection control practices (e.g., handwashing, covering their
Chapter #18: Paediatric Services
cough), they are more likely to spread the virus. Social, public health and other concerns may have an impact on services for children During a pandemic, the risk of spread among children may be exacerbated by the fact that some children may remain unimmunized even after an effective vaccine becomes available. Some parents refuse to have their child vaccinated because they do not understand the need for the vaccine, or may be concerned about its safety and/or efficacy. Their decision could have an impact on community health and on the types of public health measures required to contain the spread of the virus. Because children are more likely to spread the virus, public health authorities may consider measures such as closing schools and daycare (i.e., social distancing) as a way to reduce transmission (see chapter 6, Public Health Measures). These measures, if used, will disrupt children’s education and put more pressure on families. Influenza manifests differently in children, and will require different treatment Respiratory illness caused by influenza is nonspecific in children and can be difficult to distinguish from illness caused by other respiratory pathogens based on symptoms alone. Although influenza in children is similar to the disease in adults, there are some age-related differences in toddlers and infants associated with uncomplicated influenza. For example, children under age 5 usually present with sudden onset of fever
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and cough. Infants are less likely to cough and will frequently have only nonspecific signs such as poor feeding, apnea high fever or very low body temperature. Caring for children with influenza will be complicated because:
• young children (particularly infants) can progress to severe illness rapidly
• current antiviral agents are not approved for use with children under age 1
• resistance to oseltamivir appears to occur more frequently in children when treating seasonal influenza
• children may require different treatment than adults for complications such as pneumonia. Influenza will be a particular risk for newborns, particularly if the mother has influenza or contact with someone with influenza. Parents and other adults play a key role in caring for children at home and in paediatric settings. During a pandemic, parents and other caregivers may be too ill to provide care for their children. That will affect not only the individual child’s care but the surge capacity in paediatric care settings, which must plan to accommodate parents who can stay with their child as well as the extra health care providers required if parents are too ill to help with care. Parents’ reliance on family physicians for paediatric care. Adults may accept influenza advice from public health units, Telehealth, and other general sources. Many parents, however, will want to speak to their family physician about their children’s health. Family physicians may require support to manage requests for care of children during a pandemic.
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18.3 Strategies to Meet the Needs of Children, Youth and Families To protect children’s health and meet children’s needs as well as the needs of their family during an influenza pandemic, the health system must:
• communicate effectively with all families using a variety of media (e.g., television, radio, newspaper, Internet)
• provide age-appropriate information for children and youth
• implement infection control measures and consider public health measures to reduce the spread of influenza among children
• consider the need for child care services, particularly for the children of workers critical to societal infrastructure
• provide appropriate care for children with influenza, including care providers, equipment, supplies and laboratory support
• provide psychosocial support for families. Communication and education activities, infection control and public health measures, the need for child care services, and the health human resources issues associated with caring for children have been incorporated into the relevant sections of OHPIP (see Chapters 7, 8, 11, 12). In addition, the ethical framework for decisionmaking in a pandemic has been revised to include values specific to caring for children and youth, including family-centred care and respect for young people’s emerging autonomy (see Chapter 2). This chapter deals specifically with the paediatric services required to provide care for children with influenza and other health care needs, and to support families during a
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pandemic. Case definition for probable influenza-
18.4 Providing Influenza Care for Children Children who develop influenza will be expected to access the health care system in the same way as adults (see Chapter 11). Parents/caregivers will be encouraged to call Telehealth for advice and direction to the most appropriate setting for care for their child, to consult their primary care practitioner or – in a severe pandemic – to go to an alternative source of care, such as a flu centre. To ensure children receive timely care and reduce strain on hospital and emergency capacity, primary care providers, their staff (e.g., receptionists, nurses), parents and caregivers will need tools, information and timely access to advice from community paediatricians. To play that consulting/ leadership role with public health units and family physicians, community paediatricians will also need supports. To help health care providers care for children with influenza, the following tools have been developed (see Chapter 18A): Decision-Making Tools to Distribute to Families/Caregivers • Diagnosing and Managing Paediatric Influenza – a fact sheet highlighting signs, symptoms and management of paediatric influenza during a pandemic
• When to seek medical care for an infant or young child (up to 6 years old) with influenza-like illness and When to seek medical care for an older child (to 6-16 years old) with influenza-like illness – decisionmaking tools for parents/caregivers. Decision-Making Tools for Providers • Paediatric Pandemic Influenza Office Assessment Form – an assessment form for use in the physician’s office or flu
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like illness in children The following general clinical case definition for influenza-like illness in children has been developed to help identify probable cases. This definition applies mainly to the clinical presentation of interpandemic influenza and may need to be modified in the event of a pandemic. When influenza is circulating in the community the definition for children is as follows: Sudden onset of high fever (>38o C) and cough, along with other symptoms such as sore throat, hoarse voice, nasal congestion and/or rhinorrhea, conjunctivitis, difficulty breathing, lethargy, myalgia. Some children (particularly under the age of 3) may present with a predominance of gastrointestinal symptoms including nausea, vomiting, abdominal pain, and/or diarrhea. Children under the age of 1 year may present with only sudden onset of high fever (>38o C) or low body temperature (<36o C) and nonspecific signs such as poor feeding, excessive irritability.
centre to document the patient assessment and potential plan of care or follow-up. The form outlines assessment criteria and possible antiviral agents that may be prescribed for paediatric patients.
• Referral of Paediatric Patients with Influenza-like illness – a decision-making tool for health care providers, to help determine the type of care required and the appropriate care setting (e.g., home, doctor’s office, flu centre, hospital), which can be printed and posted in the office for reference. Levels of Paediatric Care Required Providing care at home. If the child is assessed by a primary care provider and deemed well enough to return home, parents should be directed to use the appropriate decision-making tools for parents/caregivers described above. These tools will help them care for their child at home and determine when to return for
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reassessment. In these circumstances, primary care practitioners should consider the ability of the caregiver to adequately provide for the child (e.g., is the caregiver also ill?). Caregivers who are unable to care for their child may need help accessing an alternative care provider. Hospitalization. Children who are not well enough to return home may need to be admitted to hospital. Each hospital will determine its own capacity for managing paediatric patients during a pandemic. Community and other academic hospitals should develop guidelines and admission criteria for management of children (with or without influenza), taking into account the level of care and resources required and whether the care could be provided at home or in an alternate setting. Admission to hospital should be based on immediate need and in accordance with the sample admission criteria outlined below. Sample Paediatric Admission Guidelines Unstable vital signs (e.g. tachypnea, tachycardia, hypotension etc) Oxygen saturations <92% Change in neurologic status (i.e. signs of encephalopathy/ encephalitis; seizures) hydration deemed inadequate (i.e. decreased urine output, weight loss, tachycardia) or child is unable to tolerate oral fluids secondary infection that fails to respind to oral antiobiotics or if oral antibiotics are felt to be ineffective (e.g. vomiting) invasive infection such as sepsis or meningitis
Hospitals that are less familiar with managing paediatric inpatients may need to develop a mechanism for supporting local physicians or nurse practitioners, which could be developed in advance of a pandemic (e.g., telephone consultation, provider tools/algorithms, outreach
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education). Chronic conditions. Although rates of hospitalizations and morbidity due to influenza complications are greater among children with chronic conditions, “early admission” is not a recommended strategy to prevent a more severe clinical course. Such a practice is unlikely to be effective, may further expose the child to infection, and would place an unnecessary burden on health care system capacity during a pandemic. Families of children with chronic illness should be educated, in advance, about effective prevention strategies for their child and given the appropriate tools as well as resources that tell them when to seek medical care. These families may consider “self-quarantine” as a preventative strategy rather than hospitalization. Critical care. If a child’s condition deteriorates and the level of care and resources required outstrips capacity, health care providers will arrange a consultation and referral to a higher level of care in another centre, while recognizing that complex acute and critical care centres will need to triage the patient based on their resource and surge capacity at that time in the pandemic. Implications for Infection Prevention and Control. For newborns. Since influenza will be a particular risk for newborns, caregivers should take steps to reduce the risk of being exposed to or transmitting influenza to their infant including:
• not sneezing or coughing on the baby • washing hands frequently – particularly after coughing or wiping their nose (hand hygiene)
• thoroughly cleaning surfaces in the home when someone is ill with influenza
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• avoiding activities where large numbers of people gather in enclosed spaces. (See Chapter 7: Occupational Health and Safety and Infection Prevention and Control Measures.) Depending on the pandemic strain, breast milk of mothers with influenza may be unsuitable for feeding their babies. Until this information is confirmed by health officials, mothers should continue breastfeeding and take additional precautions such as wearing a surgical mask, and practicing good hand hygiene before each feeding or other close contact with their infants. They should only discontinue breastfeeding and use an alternative source to feed their baby under the advice of their doctor. For children who are hospitalized. Children most likely to present to hospitals are those who require a great deal of handson, complex care, which creates more opportunities for transmission and greater need for personal protective equipment (see Chapter 7). Families will likely be present when a child is hospitalized during a pandemic, which will create the need for additional education and supplies, as well as possibly more opportunity to transmit infection. Isolation precautions may be more prolonged for children because they shed virus for longer periods of time. This will have an impact on capacity and make it more challenging for health care providers and family members to adhere to precautions. The environment where a child with influenza receives care is more likely to be contaminated and will require more frequent cleaning. Environmental cleaning can be challenging if there are toys, medical equipment, recreational equipment and other patient/family belongings in the
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child’s environment. For other paediatric inpatients. Other paediatric inpatients are more likely to be susceptible to influenza and have fewer treatment options if they do acquire influenza; therefore, it is important the hospitals identify cases promptly and initiate correct infection control and isolation practices immediately.
Screening Children for ILI Screening can be more complex because of the difficulties associated with diagnosing influenza in children. use Paediatric specific active screening tools use Paediatric specific passive screening signage (see Chapter 18A).
Recommended Infection Prevention and Control Practices In addition to the information in Chapter 7 (Occupational Health and Safety and Infection Prevention and Control Measures), health care providers caring for children should consider the following paediatricspecific infection prevention and control strategies: Transmission-based Precautions
• Isolate for the duration of illness (consider the range of paediatric clinical manifestations when determining asymptomatic state).
• Do not cohort patients with atypical symptoms before laboratory confirmation (when possible).
• Use paediatric-sized masks for symptomatic children who cannot be kept at least 2 metres (6 feet) away from others in waiting areas and during transport to other facility locations. Hand Hygiene
• Use developmentally appropriate products and programs to encourage
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hand hygiene among children, such as hand sanitizing wipes and age appropriate signage (see Chapter 18A).
• Instruct family members and caregivers in proper hand hygiene. Aerosol Generating Procedures
• Identify aerosol generating procedures that will likely be required in paediatric populations.
• Educate staff about how to perform these procedures safely (see Preventing Febrile Respiratory Illnesses: www.health.gov.on.ca/english/provider s/program/infectious/diseases/best_pr ac/bp_fri_092805.pdf). Environmental Management
• Provide point of care disinfectant wipes in patient care areas.
• Provide dedicated and/or disposable medical equipment for isolated patients.
• Provide washable toys and limit the sharing of age appropriate activity kits and toys from home.
• Provide storage for family belongings. Family and Visitors
• Limit the number of family members/ visitors to two designated people (whenever possible).
• Limit sibling visitors to those who are asymptomatic and >10 years of age.
• Provide family members/visitors with gowns and other personal protective equipment (as appropriate), and instruct them how to use and dispose of them properly.
• Encourage proper hand hygiene practices. Laboratory Testing Chapter 14 provides guidelines for laboratory sampling and testing for influenza during a pandemic. Guidelines for
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paediatric specimen collection are included in Chapter 14A. Consent to Treatment Settings will establish procedures to manage consent issues associated with providing care for children including:
• obtaining consent for treatment and discharge planning if caregivers of hospitalized children are themselves hospitalized or unable to provide care.
• naming substitute decision makers if parents or other family members are unavailable. Other Care Issues Access to Antivirals and Vaccine. The health risks to pre- and post-partum women, neonates and children will be taken into account in the province’s antiviral and vaccine strategy. Supports for Families. To ensure the best care for children and family members who are isolated/quarantined at home, the system must be able to provide critical services and supplies. This would include such things as food, water, shelter, medicines and medical consultations, mental health and psychological support services, other supportive services such as child care, schooling, and transportation to medical treatment, if required.
18.5 Maintaining Paediatric Care during a Pandemic During an influenza pandemic, clinicians will use a variety of strategies to meet the medical needs of Ontario’s children. Specifically, the system will have to create surge capacity for the delivery of paediatric acute and critical care (refer to OHPIP Chapter 17; Chapter 11 & 13 OHA Pandemic Toolkit for Small, Rural and Northern Hospitals). Depending on the severity of the pandemic,
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there may come a point when resources are scarce and surge strategies are no longer able to meet the needs of the children and youth requiring care. In these situations, providers will use decision-making processes to ensure effective use of scarce resources and interventions (e.g., ventilators, intensive care beds). Ethical Decision Making during a Pandemic To the extent possible, care settings should adhere to ethical standards and principles that guide decision-making for infants, children, and adolescents under nonpandemic conditions, throughout all stages of a pandemic (see Chapter 2 and Canadian Paediatric Society Position Statement (B 200401), Paediatric Child Health Volume 9 No 2 February 2004). However, in a crisis situation this may not always be possible. Parents and guardians may not be available to act as substitute decision-makers, the comforting presence of family for the hospitalized child may not be available and facilities may not have enough life-saving interventions for all those who may benefit. Decision-making in this context will require a difficult balancing of interests, rights, responsibilities and duties. Providers will strive to choose the least harmful course of action and should consider the best available scientific evidence as the starting point of decision-making. This is a key value that underpins “paediatric triage”, ensuring that the decision-making processes are based on common, known and transparent parameters, and that allocation of scarce resources is based on best possible outcomes rather than criteria associated with social worth (i.e., social status, perception of social contribution, age, disability, ethnicity). Defining Triage During a non-pandemic situation, “routine” triage involves identifying patients who require medical attention and then
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prioritizing the order in which they will receive care. Prioritization is based on the severity of symptoms and the threat to life associated with the underlying condition. Within this definition of triage, those who are the most sick and those whose life is the most threatened are attended to first, while others are attended to at a later time. In this instance, the degree and/or extent of care provided is only rarely, if ever, limited due to a lack of available resources. During a pandemic situation, once surge capacity has been exhausted and health care resources are limited, this “routine” prioritization may no longer be sufficient and the concept of “TRUE Triage” or “Targeting Resources to achieve Ultimate Ends” needs to be considered (see Chapter 17). To date, this particular model has focused primarily on decision-making and allocation of scarce resources for adults requiring admission to critical care. “TRUE Triage” does not take into account the unique circumstances and vulnerabilities of children and youth. The following guiding principles are suggested as a foundation for decision-making for care of children and youth. Guiding principles for children and youth In addition to the core values of best scientific evidence and social justice, deliberations regarding the allocation of resources and provision of care to paediatric patients should consider the following: Unique considerations of infants, children and youth
Infants and children are vulnerable and in need of protection. They are typically embedded in families who care for them and provide them with their ongoing needs. Their parents or guardians are their surrogate decision-makers for health care. Health care decisions are often challenging, as decision makers try to determine what is
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in the child’s best interests, usually without having direct access to the child’s wishes. Medications and interventions may not have been studied in children, and clinical outcomes are often less certain. As children develop they may become increasingly interested in their bodies and may wish to receive information and even be involved in decision-making. Respect for their developing autonomy supports practices that encourage children to participate in a developmentally appropriate way. At some point adolescents will become the primary decision-maker for their own care. Those who care for children have a duty to advocate for them, as the children cannot speak for themselves. Presently there are regional inequalities with regards to resources for paediatrics (even more so than adult resource inequalities). Pandemic planning should include capacity enhancements that do not exist currently (i.e., pre-pandemic) in order to deal with these inequities. Legal/ ethical obligation to care for children/ youth
From a legal and ethical standpoint, decisions made for children by others should be consistent with the child’s best interests. Preserving life and minimizing undue suffering are primary considerations. When death seems inevitable or ongoing treatment poses a greater burden than benefit for the child, options such as providing comfort care and enhancing quality of life may be reasonable and even encouraged. Parents/guardians and health care professionals should collaborate in these decisions, involving the child as appropriate. Dynamic pandemic environment
A pandemic is a dynamic environment where specific care decisions made for a
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specific child must change over time as available resources change. Decisions should be based primarily on the physiological status of the child rather than just categories of disease, illness, or treatment. Decision-makers should review each patient on an individual basis, taking into account the patient’s physiology, the presence of co-morbidities (and the relevant impact on prognosis with or without influenza) , predicted response to influenza (or another presenting illness), and the demand for resources based on the patient’s condition. Ethically non-relevant considerations (i.e., what should not be a deciding factor or an “exclusion criterion”?)
“Best interest” decisions should focus on considerations that are ethically relevant. For example, the Canadian Paediatric Society suggests consideration of the following:
• chances of survival • the harms and the benefits of treatment • evidence regarding long- and short-term medical outcomes of the treatment
• long-term implications for the child or adolescent’s suffering and quality of life. It would be unjust, not ethically relevant, and inconsistent with the Canadian Charter of Rights and Freedoms to deny treatment solely on the basis of the child’s age, gender, race, religion, socioeconomic status, geographical location (urban versus rural, north versus south, etc.) and/or the existence of a physical or mental disability. Paediatric Triage Model and Draft Guidelines Recognizing the need for critical decisionmaking and taking into account the guiding principles, OHPIP suggests the following “paediatric triage” model, which would only be applied after all other surge capacity
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and resource allocation strategies have been exhausted. Under this definition, triage does not become a method of deciding which child will or will not receive care. Instead, “paediatric triage” presumes that every paediatric patient will receive care. However, as the pandemic evolves, the environment changes, and resources become limited, the system will develop processes and criteria to decide how, when, and what health resources can and will be allocated to each child. As the pandemic evolves, paediatric triage will become a fluid and dynamic process very much dependent upon patient demands as well as the availability of resources. The purpose of the draft guidelines is to provide a framework for deciding about two levels of resource allocation that must be considered concurrently when making decisions: levels of resource intensity and levels of patientspecific triage (see Table 1). Levels of Resource Intensity
This category focuses on resource utilization as the basis of allocation. As the availability of resources and the ability to provide rudimentary critical care become compromised, providers must consider limiting resource-intensive therapies for all patients, regardless of prognosis.
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The second category – Levels of PatientSpecific Triage – prompts the provider to consider patient-specific predicted outcome as the basis for resource allocation. In this instance, the intention is to match the provision of critical care resources and interventions to those patients with the greatest potential for benefit (i.e., maximal survival, minimal morbidity). While the issues of triage are clearly linked to capacity, this document does not make specific recommendations about interventions to increase, maintain or shift capacity within health care institutions or settings. Guidelines for each level of resource allocation have been organized explicitly to reflect the step-wise shift from providing critical care to all patients to caring for as many as possible as the pandemic progresses. The levels of resource allocation for both categories are numbered based on the stage of the pandemic. In the early pandemic period, care settings will still have the ability to flex surge capacity, while in the late pandemic period, settings may experience resource shortages that will dictate who will receive critical care and which therapies will be provided.
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Table 18.1: Levels of Resource Allocation for Paediatric Triage during a Pandemic
Resource Intensity Provision
Paediatric Patient-specific Triage
Level 1: Early Pandemic Period Continue to provide the full range of pediatric/neonatal ICU therapies by maximizing access to technological and human resources
Level 1: Early Pandemic Period Maximize capacity within units, within hospital (e.g., paediatric and adult ICU, ED, NICU), and within region to provide critical care to all patients.
Level 2: Mid Pandemic Period Limit specific resource-intensive therapies which are only available in paediatric/neonatal ICUs Examples of Resource-intensive Therapy:
Level 2: Mid Pandemic Period Time-limited trials of ICU therapy (e.g., 24 hours) and accelerated decision-making processes to withhold/ withdraw life support for patients not predicted to survive ICU-related diagnoses
•
Continuous Renal Replacement Therapy (CCRT), Extracorporeal Membrane Oxygenation (ECMO), Nitric Oxide (NO)
Paediatric Examples: • Post-cardiac arrest patients, severe sepsis with multiorgan failure, severe head trauma with Glasgow coma scale = 3 and refractory intracranial pressure, patients with greater than 30% third-degree burns, severe refractory acute respiratory distress syndrome Neonatal Examples: • Prolonged neonatal resuscitation, severe hypoxicischemic encephalopathy (Sarnat III or with multi-organ failure), severe intraventricular hemorrhage (bilateral grade III/IV), severe refractory persistent pulmonary hypertension of the newborn
Level 3: Late Pandemic Period
Level 3: Late Pandemic Period
Limit resource-intensive therapies for conditions that require care beyond paediatric ICU or require prolonged NICU stay. In a full-blown pandemic, there may be interventions or programs that would be suspended. Provision of intensive care as a bridge to the interventions or programs that are suspended would not be a judicious use of resources as the burden of treatment would be experienced without any hope of benefit. Examples of Resource-intensive Conditions:
Limited access to ICU for patients with underlying chronic conditions associated with known or predicted severe morbidity, as well as those patients included in level 2 Paediatric Examples: • Late-stage degenerative conditions requiring chronic life support measures, lethal chromosomal/genetic disorders, late-stage neurodegenerative disorders, persistent vegetative state with no chance of recovery Neonatal Examples: • Extreme prematurity and extremely low birth weight, lethal chromosomal/genetic disorders, severe lifethreatening complex congenital anomalies
• Organ transplantation, bone marrow transplantation, neonatal surgery for severe life-threatening complex congenital anomalies, extreme prematurity and extremely low birth weight
Operationalizing Triage In planning for an influenza pandemic, settings that provide acute and critical paediatric services should consider the following:
• advise families of the need to consider a
• providers caring for children and youth,
• should a pandemic reach a stage where
along with children’s parents/guardians, and when appropriate the children themselves, should make specific treatment decisions that allocate resources based on best possible outcomes.
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plan for their children, including an alternative care provider/decisionmaker, in the event that the parent became incapacitated. all surge capacity strategies are exhausted and life saving interventions and resources cannot be made available, specially trained decision-makers (i.e., triage officers) or teams may be asked to decide whether or not a specific patient
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fits a pre-determined category to receive the scarce resources, and if not, what level of care will be provided.
• assemble a multidisciplinary triage team or appoint a triage lead to support the triage process, ensure consistency in the approach to decision-making, and enable an appropriate response to changing needs and information throughout the pandemic.
• establish a triage process that is open, transparent, reasonable and inclusive to help guide decision-making with respect to the level/type of care required and the setting in which care can be provided for patients with influenza (i.e., clinic, community hospital, tertiary hospital, home).
• to help health care providers in establishing a triage process, the following tool has been developed: Decision Making Process for Neonatal Intensive Care – a tool for health care providers to use in a neonatal Intensive Care setting. This tool can be adapted to other critical care and non-critical care settings (Refer to Chapter 18A).
18.6 Maintaining Obstetrical Care during a Pandemic In addition to providing paediatric services during a pandemic, Ontario must maintain capacity to provide routine obstetrical services. Planning and preparation must be done to be able to respond to the needs of pregnant women, who are likely to experience complications associated with influenza. Women who contract influenza in the second and third trimester of pregnancy are more likely to experience stillbirths and are at higher risk of cardiorespiratory illness. Primary care services must be able to assess and manage pregnant women who present
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with symptoms of influenza. For information specific to the medical management of obstetric patients during a pandemic, see Chapter 18A.
18.7 Coordinate planning with other obstetric and critical paediatric services An influenza pandemic will affect the entire community, and the demand for health care resources will be particularly high. All parts of the health care system must be involved in planning to respond to influenza-related needs and maintain other critical health services during a pandemic. Settings that provide obstetrical and critical paediatric services cannot plan in isolation; therefore, they should:
• develop an inventory of current and surge capacity, including physical as well as human resources (e.g., acute care beds, special needs beds, birthing suites, NICU, PICU, transport services, staffing levels, skill mix). See Chapters 8 and 17.
• assess the equipment, supplies and resources required to maintain obstetrical and paediatric services in each setting (e.g., home, clinic, doctor’s office, community general hospital, rehabilitation and special needs agencies, tertiary paediatric hospital, transport).
• identify alternative feeding sources if breast milk of mothers with influenza is considered unsuitable.
• connect with other health organizations in the community, including local and/or regional obstetric and critical paediatric service providers, hospitals, community care access centres (CCACs), emergency medical services, and local public health units.
• share planning assumptions and pandemic plans and/or develop mutual
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aid agreements between settings and/or regions to optimize hospital and nonhospital resources and management of paediatric, neonatal and obstetrical cases.
• develop strategies to help maximize physical capacity, clinical practices and the use of staff and providers in responding to care needs (See Chapter 17, as well as the OHA Pandemic Toolkit for Small, Rural and Northern Hospitals, Chapter 11 & 13).
• deploy and redeploy staff to ensure adequate coverage of obstetric and critical paediatric services using a competency based framework (see Chapter 8). This process will include assessing: •
the type and level of service to be provided
•
the spectrum of competencies required to meet patient needs
•
the competencies that providers can supply
•
the gap in competencies
•
the strategies required to build staff and provider capacity.
• explore opportunities for collaboration, pooling and/or sharing of resources during a pandemic particularly in areas or regions where the number of specialized providers is limited.
• consider alternative sites to provide services that can be managed in a different way during a pandemic (e.g., pre- and post-natal visits, well baby visits in a community centre, or phone) to help preserve hospital capacity for more acute or critical levels of patient care. Midwives Midwives are an integral component of obstetrical services in Ontario and a key
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resource to include in human resource and service delivery planning, particularly in areas or regions where the number of specialized providers is limited. Policies regarding hospital admitting privileges and/or credentialing for midwives should be examined in advance of a pandemic, and procedures should be put in place to facilitate midwives’ full inclusion in the hospital setting. This will ensure hospitals have the maximum number of maternity care providers to help maintain obstetric service capacity during a pandemic. Midwives’ current provision of obstetrical care in alternative settings should be explored for its potential to help maintain community obstetric service capacity in a pandemic. Identify alternate ways to deliver some services • Advise patients and families to call the office or Teleheath, rather than coming to the hospital, clinic or office, providing them with as much care and advice by phone as possible.
• Give patients and families information about emergency planning and preparedness, how to protect themselves from flu and how to care for family members who become ill. Refer to the ministry fact sheets: (http://www.health.gov.on.ca/english/ public/program/emu/pan_flu/pan_flu _materials.html#fs), as well as the selfcare and self-assessment tools developed specifically for children, pre- and postnatal women (See Chapter 18A).
• Explore alternative models of care for antenatal, labour and delivery, and post partum care that would maximize safety, efficiency, and system capacity.
• Delegate some care and/ or components of service to other providers who have the required skills and competencies to
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support the care (See Chapter 8 for competency based health human resources planning framework).
• Establish pre-natal and antenatal care protocols to ensure that there is a system in place to meet the needs of normal and high-risk pregnancies (e.g., earlier discharges for vaginal births, such as a six-hour length of stay following childbirth, which is consistent with current midwifery practice; telephone consults in lieu of hospital visits for healthy moms and healthy newborns). To help health care providers establish care protocols, the following tools have been developed (see Chapter 18A):
• Obstetric Medical Management for Pandemic Influenza – a decision-making tool for health providers, highlighting signs, symptoms and management of antepartum, intrapartum and postpartum women with influenza
• Clinical Guidelines for Early Discharge Following Uncomplicated Vaginal Birth – a checklist for health care providers to facilitate patient assessment and planning for early discharge (i.e. < 6 hours post partum) following an uncomplicated vaginal birth
beginning labour with influenza, as well as some self care and monitoring instructions. Identify services that can be reduced or deferred during a pandemic In an effort to enhance surge capacity during a pandemic, care settings should identify those obstetric and critical paediatric services that could be deferred for a period of time or that could be managed differently, as well as those services that cannot or should not be deferred. Table 2 provides examples of obstetric services in each of these three categories. Further information suggesting alternate models of low risk, prenatal care is available in Alternate Model of Prenatal Care – a fact sheet for prenatal care providers during a pandemic (see Chapter 18A). A similar approach was taken to develop the decision-making process tool for health care providers in the neonatal intensive care unit. The tool highlights examples of care provided in the neonatal intensive care unit that can/cannot be deferred or managed differently (see Chapter 18A). This tool, as well as the table below, could be adopted for use in both acute and critical care paediatric settings to help identify services that can and cannot be deferred.
• Early Discharge Postpartum Follow-up Guidelines – a checklist for health care providers highlighting maternal and newborn assessment parameters, teaching, interventions, and further follow-up if required. Prior to a pandemic, advise patients and families how service delivery and care routines may change during a pandemic (see Chapter 18A) – Pandemic Influenza and Pregnancy – a fact sheet for women expecting a baby during a pandemic, highlighting signs, symptoms and when to seek medical attention if pregnant or
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Table 2: Examples of Obstetric Care Services that Can or Cannot be Deferred
Trimester I
Trimester II
PRIORITY A
PRIORITY B
PRIORITY C
Patients requiring care/ treatment that cannot / should not be deferred
Patients requiring care/ treatment that can be deferred for a defined period of time
Patients requiring care/ treatment that can be deferred or can be managed in an alternate way
Termination of significant fetal anomaly (TOFA) and first prenatal visit for patients with significant medical disorders requiring urgent medical attention
First prenatal visit could be extended to 14 weeks First Trimester Screening or Integrated Prenatal Screening could be extended to 16 -19 weeks
Chorionic Villi Sampling could be deferred with backup amniocentesis at 16 weeks
Termination of significant fetal anomaly (TOFA), management of complex maternal or fetal condition, amniocentesis for conditions at significant risk, and anatomy ultrasound.
Amniocentesis (depending on the level of risk)
Routine prenatal visit
First Trimester Screening and/ or Integrated prenatal Screening to be replaced with Maternal Serum Screening
Management of complex maternal or fetal condition, ultrasound for pregnancies and fetuses at risk. Delivery cannot be deferred
Routine prenatal visit, glucose challenge test, CBC Routine 3rd trimester ultrasound.
Management of postpartum hemorrhage, infection of the breast, uterus or wound
Routine postpartum visit could be deferred or managed in another setting (e.g., outpatient clinic, home visit, self-care)
18.6 Providing Psychosocial Support
workers, psychologists, guidance counselors, hospital-based chaplains and other helping professionals – to help children, youth and caregivers cope
Trimester III
Post-natal
During an influenza pandemic, parents and families may need psychosocial support to help them cope with fear, the illness of a child, frustration over the lack of treatment options (i.e., no vaccine), decision-making about a child’s care, the stress of having family members isolated, the competing demands of caring for ill family members and work, and multiple deaths among family and friends. Local pandemic plans will:
• identify psychosocial services and resources available – including cultural and faith groups, teachers, school social
Chapter #18: Paediatric Services
• develop strategies to facilitate death rites, funeral rituals, grief and bereavement in the context of a pandemic. The issues of psychosocial support and grief and bereavement services will be covered in more depth in future iterations of OHPIP.
18.7 Maintaining Education During a pandemic, every effort must be made to help children lead a normal life, including continuing school. The Ministry of Education and school boards need to plan
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Ontario Health Plan for an Influenza Pandemic August 2008
alternative education strategies for the ill or convalescing child and for all children in the case of school closures.
18.8 Next Steps MOHLTC will continue to work with paediatric service providers to refine plans to provide care for children during a pandemic. The paediatric working group will be seeking input from key stakeholders on the guiding principles, ethical decisionmaking and draft guidelines for the triage of paediatric patients during a pandemic situation set out in this chapter. In addition, the working group will continue to explore the issues of psychosocial support and grief and bereavement services. MOHLTC will also work with the Ministry of Education to develop alternative education strategies during a pandemic.
Chapter #18: Paediatric Services
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18A. Pediatric Services Tools
Contents Parent/Caregiver Tools When Your Child is Sick With Uncomplicated Influenza.................................................................... 1 Measuring a Child’s Temperature and Breathing................................................................................. 2 What to do for Fever in Children............................................................................................................. 4 When to Seek Medical Care for an Infant or Young Child under 6 years old .................................. 6 When to Seek Medical Care for a child from 6 to 16 years old............................................................ 7 Pandemic Influenza and Pregnancy fact sheet ...................................................................................... 8 Provider Tools Diagnosing and Managing Pediatric Influenza ................................................................................... 12 Decision Making Tool for Referral of Pediatric Patients with Influenza-like Illness ..................... 16 Pediatric Pandemic Influenza Office Assessment Form .................................................................... 17 Pediatric Specific Passive Screening Signage ....................................................................................... 19 Cough and Sneeze Signage..................................................................................................................... 20 DRAFT Decision Making Process for Neonatal Intensive Care ....................................................... 21 Obstetric Medical Management for Pandemic Influenza................................................................... 22 DRAFT Preparation for Discharge – Uncomplicated Vaginal Birth................................................ 32 DRAFT Early Discharge Postpartum Follow-up Guidelines ........................................................... 33 DRAFT Alternate Model of Prenatal Care during a Pandemic......................................................... 34
Ontario Health Plan for an Influenza Pandemic August 2008
When Your Child is Sick with Uncomplicated Influenza This fact sheet provides information for parents
• Offer cool fluids frequently when the
and caregivers about managing signs and symptoms of uncomplicated influenza at home. Influenza in Children
Older children and teens have the same symptoms of influenza as adults, including fever, headache, aches and pains, fatigue, stuffy nose, sneezing, sore throat and cough. Children under age 5 usually present with sudden onset of fever and cough. Infants are less likely to cough and will frequently have only nonspecific signs such as poor feeding, apnea high fever or very low body temperature. Younger children – particularly children under 6 months old – may also have diarrhea, vomiting and stomach pain.
• •
Very young children and infants probably have aches and pains but do not know how to tell people they have head, body or stomach pain. They may be irritable and eat poorly. They sometimes develop a hoarse cry and barking cough (croup).
•
What You Can Do For Your Child
• Give acetaminophen or ibuprofen for
• •
•
fever and muscle pain in the dose recommended on the package (unless your doctor says otherwise). DO NOT GIVE ASPIRIN or ASA. Children under 18 should not take acetylsalicylic acid (ASA) or products contacting ASA. Your pharmacist can provide advice on appropriate over-the-counter medications for treating fever. Do not expect to be prescribed antibiotics for uncomplicated influenza, as they will not help. Antibiotics may be prescribed for complications of influenza such as pneumonia or ear infection. Dress the child in lightweight clothing and keep the room temperature at 20° C.
Chapter #18A: Paediatric Services Tools
• •
•
•
child is awake. Extra fluids are needed to replace what is lost in sweating. If your child’s urine is darker than usual, he/she needs more to drink. Avoid cool baths. Allow the child to rest and stay at home if possible for 6 days or more, so the virus isn’t spread to other children. Use salt-water or saline nose drops to treat a stuffy nose. Teach the child to cover his/her mouth and nose with a tissue when coughing or sneezing and then to throw the tissue away. Wash your hands often with soap and warm water or an alcohol-based hand sanitizer and teach your child to do the same after wiping the nose. If you don’t have a tissue, cough or sneeze into your upper arm, not into your hands, and teach your child to do the same. Don’t share eating utensils (e.g., cups or straws), toothbrushes or towels with your child.
When to Seek Medical Care
Use the following decision-making tools to help you decide when to seek medical care: When to seek medical care for an infant or young child (under age 6) When to seek medical care for older children or adolescents (6-16 years old) For More Information
Visit our website at: www.health.gov.on.ca/pandemic INFOline: 1-866-801-7242 TTY 1-900-387-5559 Telehealth: 1-866-797-0000 TTY : 1-866-797-0007
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Measuring a Child’s Temperature and Breathing This fact sheet provides information for parents and caregivers about how to take a temperature and how to measure breathing in children.
Ask the pharmacist any questions you may have when you purchase your thermometer.
Ways to Take a Temperature
There are 3 ways to take a child’s temperature: • by the mouth (oral) • under the armpit (axillary) • in the ear (tympanic) The best method to choose for an exact reading depends on your child’s age: Age Best 2nd Best 3rd Best Birth - 2
Armpit
2-5
Ear
Armpit
5 - adult
Mouth
Ear
A fever strip is not recommended because it does not give an accurate temperature reading.
Armpit
What is a Normal Temperature?
Mouth: 35.5°C to 37.5°C (95.9°F to 99.5°F) Armpit: 34.7°C to 37.3°C (94.5°F to 99.1°F) Ear: 35.8°C to 38°C (96.4°F to 100.4°F) Types of Thermometers
There are two types of thermometers for taking temperatures by mouth and armpit: • a glass thermometer has a long slender bulb at one end, containing mercury. As the mercury expands, in response to the heat from the child’s body, it moves up the column. Use of a glass thermometer is not recommended for children under 5 since they may bite down, breaking the glass and injuring themselves. If you are purchasing a glass thermometer, look for one with a mercury column that is easy to see, and degree markings that are easy to read. • a digital thermometer is made of sturdy plastic, is easy to read and measures temperature faster than glass. Ear thermometers are available but are expensive.
Chapter #18A: Paediatric Services Tools
How to Take a Child’s Temperature
Mouth Method (Oral) If you are using a glass thermometer: Note: this method is not recommended for children under 5 years of age. • Be sure it is an oral thermometer. • Clean the thermometer with cool, soapy water and rinse (hot water causes the mercury to expand and may burst the thermometer). • Hold the thermometer at the end away from the mercury and shake it with firm downward flicks of the wrist so that the mercury goes below 36°C (96.8°F). • Do not give the child cold or hot liquids for half an hour before taking his/her temperature. • Carefully place the tip of the thermometer under the child’s tongue. Tell him/her to close the mouth but not to bite down. • With the child’s mouth closed, leave the thermometer in place for 3 to 4 minutes. Stay with child and make sure he/she remains still. • Remove thermometer; hold it near the light and slowly turn it until the line of mercury is seen. Read the thermometer where the line of mercury ends. • Clean the thermometer with cool soapy water and rinse. Use a cotton swab soaked in alcohol to rub down the thermometer. • Store the thermometer in a container to prevent breakage. If you are using a digital thermometer: • Press the button to turn the thermometer “on”. • Put the thermometer tip under your child’s tongue and tell him/her to close the mouth. • Wait for the thermometer to beep. • Read the temperature on the display. 18A- 2
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• Press the button to turn the thermometer off. • To clean a digital thermometer, wash only the tip with soap and warm (not hot) water and wipe off with alcohol after use. Dry well. Armpit Method (Axillary) If you are using a glass thermometer: • Clean the thermometer and shake down the mercury as in “mouth method”. • Place the silver tip of the thermometer in the center of the armpit. • Make sure your child’s arm is tucked snugly against his/her body. • Leave the thermometer in place for at least 4 minutes. • Remove, read, clean and store the thermometer as in “mouth method”. If you are using a digital thermometer: • Press the button to turn the thermometer “on”. • Put the thermometer under your child’s armpit. The silver tip must touch the skin. • Hold the top of the thermometer with one hand and hold down your child’s arm with the other hand. • Wait for the thermometer to beep. • Read the temperature on the display. • Press the button to turn the thermometer off. • To clean a digital thermometer, wash only the tip with soap and warm (not hot) water and wipe off with alcohol after use. Dry well. Ear Method (Tympanic) If you are using an ear thermometer: • Note: This method is not recommended for children under one year of age. • Use a clean probe tip each time, and follow the manufacturer’s instructions carefully. • Gently tug on the ear, pulling it up and back. This will help straighten the ear canal, and make a clear path inside the ear to the eardrum. • Gently insert the thermometer until the ear canal is fully sealed off.
Chapter #18A: Paediatric Services Tools
• Squeeze and hold down the button for one second.
• Remove the thermometer and read the temperature. How to Measure Breathing
• For older children watch the chest rise and fall.
•
•
•
Use a watch or clock and count the number of times the chest rises (or expands) in one minute (60 seconds). Children and infants use their stomachs to breathe. You should uncover the child so you can see their stomach. Count the number of times the stomach or chest rises in 60 seconds using a watch or clock. Compare the number you counted to the chart below. If the child’s breathing rate is equal to or higher than the number in the chart, it is a sign your child is having trouble breathing, and you should seek medical attention. If the child has other symptoms or behaviours you are concerned about, contact your doctor or Telehealth for advice.
Age
Number of breaths per minute
< 2 months
> 60
2-12 months
> 50
12 months- 5 years
> 40
>5 years
> 30
For More Information
Visit our website at: www.health.gov.on.ca/pandemic INFOline: 1-866-801-7242 TTY 1-900-387-5559 Telehealth: 1-866-797-0000 TTY : 1-866-797-0007
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What to do for Fever in Children This fact sheet provides information for parents and caregivers about what to do when a child has a fever.
If Your Child Has a Fever
• Take off heavy clothing and blankets. • Dress the child in lightweight clothing and keep the room temperature at 20° C.
• Give lukewarm sponge or tub baths. • •
• •
•
•
• •
Avoid cool baths and never use alcohol rubs to bring down a fever. Offer cool fluids frequently when the child is awake. Give acetaminophen or ibuprofen for fever and muscle pain in the dose recommended on the package (unless your doctor says otherwise). DO NOT GIVE ASPIRIN. Children under 18 should not take acetylsalicylic acid (ASA) or products contacting ASA. Your pharmacist can provide advice on appropriate over-the-counter medications for treating fever. Allow the child to rest and stay at home if possible for 6 days or more, so the virus isn’t spread to other children. Teach the child to cover his or her mouth and nose with a tissue when coughing or sneezing and then to throw the tissue away. Wash your hands often with soap and warm water or an alcohol-based hand sanitizer and teach your child to do so after wiping the nose. If you don’t have a tissue, cough or sneeze into your upper arm, not into your hands, and teach your child to do the same. Don’t share eating utensils (e.g., cups or straws), toothbrushes or towels with your child. See How to Take a Temperature.
Chapter #18A: Paediatric Services Tools
What are Fever Seizures?
A fever seizure is a convulsion (a fit) in a child caused by a rapid rise of body temperature to over 39° C (102.2° F). Most seizures occur within the first day of the child becoming sick and not always when the fever is the highest. Sometimes the seizure is the first sign of a fever in an infant or child. Signs of a Fever Seizure
Your child may: • Experience sudden stiffness of the muscles of the face, arms, or legs on both sides of the body. • Begin to have jerky movements. • Fall if standing. • Pass urine. • Stop breathing and may begin to turn blue. • Not respond to voice or touch. • Cry or moan. A simple fever seizure will stop by itself with a few seconds to 5 minutes. It is followed by a brief period where the child is sleepy or confused. A complex fever seizure lasts longer than 15 minutes, occurs unevenly affecting one part of the body more than the rest, or happens again during the same illness. If Your Child Has a Fever Seizure
• Stay calm. • Leave your child on the floor (you may want to slip a blanket under the child if the floor is hard).
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• Loosen tight clothing, especially around • •
• • •
the neck. Move the child only if he or she is in a dangerous location. Turn the child on his or her side or stomach to protect the head and to prevent the child from choking if he or she throws up. Don’t hold your child down. Don’t force anything into the mouth as this increases the risk of injury. Observe the child closely and time the fever seizure so you can tell the doctor what happened.
When to Seek Medical Attention
• If the child recovers on his/her own, call • • •
your doctor or Telehealth for advice. Take your child to see a doctor as soon as possible after the first fever seizure. If the seizure lasts longer than 5 minutes, call 911 and have an ambulance take your child to the hospital. If your child has repeated seizures during the same illness or if this looks like a new type of seizure for your child, take the child to see a doctor.
Chapter #18A: Paediatric Services Tools
Managing Further Fever Seizures
If your child has a history of fever seizures and has a fever: • Give your child acetaminophen at the first sign of fever. • Sponge or bathe your child in lukewarm water; you may want to apply cool washcloths to the forehead and neck. • Offer your child cool drinks. For More Information
Visit our website at: www.health.gov.on.ca/pandemic INFOline: 1-866-801-7242 TTY 1-900-387-5559 Telehealth: 1-866-797-0000 TTY : 1-866-797-0007
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When to seek medical care for an infant or young child under 6 years old with Influenza-like illness DECISION MAKING Tool for Parents/ caregivers
START Does your child have any of the following?
□ □ □ □ □
Is an infant under 2 months of age and has a temperature higher than 38°C or lower than 36°C (armpit)- -see Measuring a Child’s Temperature and Breathing Severe trouble breathing/ fast breathing--see Measuring a Child’s Temperature and Breathing Blue lips, cold feet, hands and/ or toes; sudden paleness Limp or unconscious; abnormally sleepy; difficult to wake Extreme lack of energy; not interested in toys or playing
□ □ □ □ □ □ □
Unable to breastfeed or not drinking fluids Does not urinate(pee)/ have a wet diaper at least every 6 hours Continuous vomiting Severe diarrhea Stiff neck, sensitive to light Convulsions or seizures-see What to do for Fever in Children Full fontanelle (swollen soft spot on head)
NO
YES
Possible cause: influenza with complications. Call 911 or go to the closest emergency department
Does your child have a fever plus any of the following?
□ □ □ □ □
Chronic heart or lung disease requiring regular medical care A Chronic illness such as diabetes, cancer which is being treated; disease or treatments that affect the immune system Kidney disease A condition requiring regular ASA (acetylsalicylic acid)
YES
Hard to wake up; unusually quiet or unresponsive
For advice, call your Doctor or Telehealth (1-866-797-0000; TTY: 1-866-797-0007)
NO
Does your child have a fever plus any of the following?
□ □ □ □ □ □
Possible cause:
Irritability Eating poorly Hoarse cry Barking cough Diarrhea or vomiting
YES
Uncomplicated influenza. Refer to When Your Child is Sick With Uncomplicated Influenza or call Telehealth (1-866-797-0000; TTY: 1-866-797-0007) or go to your doctor or the Influenza Assessment, Treatment and Referral Centre closest to you
Stomach pain
NO If your child’s symptoms or behaviors are not on this chart and you are concerned, call your doctor or Telehealth number (1-866-797-0000; TTY : 1-866-797-0007) for advice
Chapter #18A: Paediatric Services Tools
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When to seek medical care for a child from 6 to 16 years old with Influenza-like illness
START Does your child have any of the following? YES
NO
Does your child have any of the following?
□ □
Short of breath while resting or doing very little Finds breathing very difficult or painful Wheezing
□
YES
A temperature of over 39°C-see Measuring a Child’s Temperature and Breathing
□ □
Vomiting for more than 4 hours
Possible cause: influenza with complications. Call 911 or go to the closest emergency department
Does your child have a sore throat, stuffy or runny nose?
YES
Possible cause: Cold.
Hard to wake up, unusually quiet or unresponsive
Follow treatment guidelines in When Your Child is Sick With Uncomplicated Influenza
NO
Does your child have any of the following?
□
Chronic heart or lung disease requiring regular medical care
□
A Chronic illness such as diabetes, cancer which is being treated; disease or treatments that affect the immune system
□ □
YES
For advice, call your Doctor or Telehealth (1-866-797-0000; TTY: 1-866-797-0007)
Kidney disease A condition requiring regular ASA (acetylsalicylic acid)
NO
Does your child have any of the following?
□ □ □ □ □
Possible cause:
Aching muscles Headache Extreme tiredness
YES
Sore throat Runny or stuffy nose
NO
Uncomplicated influenza. Refer to When Your Child is Sick With Uncomplicated Influenza or call Telehealth (1-866797-0000; TTY: 1-866-7970007) or go to your doctor or the Influenza Assessment, Treatment and Referral Centre closest to you
If your child’s symptoms are not on this chart and you are concerned, call your doctor or Telehealth number (1-866-797-0000; TTY: 1-866-797-0007) for advice Chapter 18A: Paediatric Services Tools
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Pandemic Influenza and Pregnancy This fact sheet provides information for women who are expecting a baby. What is an influenza pandemic?
An influenza pandemic is a flu outbreak that spreads quickly, affects a large proportion of the population over a wide geographic area, and causes more serious illness than seasonal influenza. How does an influenza pandemic start?
The viruses that cause ordinary/seasonal influenza – or “flu” – are constantly changing. An influenza pandemic starts when a new strain of influenza virus emerges. Because people have no immunity to the new strain, it can spread quickly and infect hundreds of thousands of people. Influenza pandemic strains can develop when an animal or bird virus mixes with a human virus to form a new virus. What is the difference between the ordinary/seasonal influenza and an influenza pandemic?
The symptoms are the same: fever, headache, aches and pains, tiredness, stuffy nose, sneezing, sore throat and cough. However, they can be much more severe with pandemic influenza and affect people who do not normally suffer as much from seasonal influenza – such as younger, healthy adults. Both ordinary or seasonal and pandemic influenza are spread in the same ways: • someone infected with the virus coughs or sneezes, and droplets containing the virus come in contact with another person’s nose, mouth or eyes (droplets from coughing and sneezing can spread up to 2 metres). • someone infected with the virus coughs or sneezes into their hands and contaminates things they touch, such as a door handle. Other people can become infected if they touch the same object and then touch their face.
Chapter #18A: Paediatric Services Tools
What will happen if an influenza pandemic hits Ontario?
An influenza pandemic will likely make its way around the world within about three months. Once the virus arrives in Ontario, it will likely spread quickly. Many people will become ill, and there will be a lot of pressure on our health care services. Depending on how widespread the influenza pandemic is, our daily routines may be disrupted. For example, companies may have to close down some of their operations. Cities may decide to provide essential services only in some areas. Public health officials may cancel public gatherings, such as concerts and sporting events, where the influenza virus can spread easily. They may close schools and the provision of healthcare services may change. We cannot predict just how Ontario will be affected until we know how strong the virus is. One way we are preparing for a pandemic is by making sure that people have the information they need to make their own personal plans to deal with pandemic influenza. This fact sheet provides information for women who may be expecting a baby during a pandemic. How will pandemic influenza affect me?
Pandemic influenza is not the same disease as ‘bird flu’ (also known as ‘avian influenza’). Pandemic influenza is expected to be like a severe bout of ordinary influenza. The illness typically begins quite suddenly. The main symptoms of pandemic influenza are likely to be: • fever with high temperature of 38°C (or higher) and chills • a cough • headache • blocked or runny nose • generalized muscle aches
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The fever will last 2 to 4 days, but the cough may go on longer. You can expect to recover from the main symptoms of pandemic influenza within 7 days.
• coughing up blood • fever lasting longer than 4 days and not getting •
How will pandemic influenza affect my unborn baby?
Some of the symptoms of influenza, such as high fever, can be a risk for your unborn baby, so you should seek care and treat a fever right away. Only take treatments, such as antiviral medication, on the advice and under the supervision of a qualified doctor or a nurse. Before taking any type of medication during pregnancy consult your pharmacist, and/or doctor, or the MOTHERISK home line: (416) 813-6780 or website: http://www.motherisk.org/women/index.jsp What should I do if I catch pandemic influenza
better starting to feel better but then developing high fever and feeling unwell again.
If you have any of these symptoms call your doctor, or go to the nearest emergency department. What should I do about appointments with my doctor or hospital?
If you have a routine ante-natal appointment with your doctor, midwife or at a hospital (e.g., for a blood test or a scan) please telephone the day before the appointment to check whether it will go ahead. Doctors’ offices and hospitals are likely to be shortstaffed during a pandemic, and non-urgent appointments may have to be postponed or cancelled. Do not attend your appointment if you have influenza symptoms.
while I am pregnant?
Once the start of a pandemic has been announced you should watch out for the symptoms of pandemic influenza, especially for a sudden high fever. If you catch pandemic influenza while you are pregnant the symptoms are likely to be quite severe. For advice, call your Doctor or Telehealth (1-866797-0000; TTY: 1-866-797-0007) or go to the Influenza Assessment, Treatment and Referral Centre closest to you. Pandemic influenza may increase the risk of a miscarriage. If you develop influenza and you experience stomach pains, cramps, or bleeding contact your doctor or midwife for advice. If bleeding is significant you should go to the nearest Emergency department. If you are more than 6 months pregnant …
If you develop influenza and are more than 6 months pregnant you should telephone your doctor or midwife to inform them that you are ill. It should not be necessary for you to visit your doctor unless you experience any of the following symptoms: • shortness of breath while at rest • painful or difficult breathing
Chapter #18A: Paediatric Services Tools
What can I do if my appointments with my doctor or hospital are cancelled?
If your routine ante-natal appointments are cancelled or postponed, and your doctor or midwife have determined that you have no identifiable risks associated with your pregnancy, you can do some things at home to help keep an eye on your weight, blood pressure, urine and movements of your unborn baby. These activities, in addition to regular telephone contact (every 4 weeks up to 32 weeks gestation; every 2 weeks until 36 weeks gestation; every week until your due date) with your doctor or midwife will help you maintain communication with him/her and give you an opportunity to discuss any concerns you have. How to test your urine
Your doctor’s office or ante-natal clinic will provide you with a number of dip sticks for testing your urine for glucose and protein. These dip sticks can also be obtained from your local pharmacy. It is important not to touch the coloured pads on the stick and to store them in a cool, dry place away from direct sunlight. Your care provider will tell you how often s/he would like you to test for glucose 18A- 9
Ontario Health Plan for an Influenza Pandemic August 2008
(sugar) and protein in your urine. When testing your urine follow the instructions below: 1.
2.
Collect a fresh urine specimen in a clean dry container. A first morning specimen is preferred but not necessary. Remove one strip from the container and dip all the test pads into the urine. The important pads for you to observe will be the third and fourth patches from your fingertips (G= glucose; P= protein. See diagram below). G
• Take your blood pressure at the same time of day.
• Use the same arm whenever you take your blood pressure.
• Avoid food and caffeine for 30 minutes before taking a measurement.
• Sit down and rest comfortably with your back
•
P
Urine Labstix®
3. Immediately remove the strip from the urine, gently sliding it against the edge of the container to remove excess urine. 4.
Tips for Accurate Measurement:
Timing is important for accurate test results. Check your watch as you dip the strip into the specimen. At 30 seconds you need to check the glucose pad for any colour change. At 60 seconds, you need to check the protein pad for any color change. If either the glucose or protein pads on the strip change color and become darker, you should call your care provider or ante-natal clinic for further instructions.
How to measure your blood pressure
Checking your blood pressure is an important part of monitoring your pregnancy for any complications. Your provider will tell you how often to take your blood pressure and when to call with the results. As a general rule if your blood pressure is greater than 140/90 or there has been a significant increase from your “normal”, you should contact your health care professional. If you have a blood pressure cuff at home and are comfortable using it, you should do so. If you do not have a blood pressure cuff at home, you could consider renting or purchasing one.
Chapter #18A: Paediatric Services Tools
•
supported and both feet on the floor for at least five minutes before measuring your blood pressure. Ensure that your arm is supported on a table or desk at about heart level. If you have your own blood pressure cuff, make sure it is the right size. It should fit smoothly and snugly around your upper arm with enough room to slide a fingertip under the cuff. The bottom of the cuff should be about one inch above your elbow.
Monitoring your baby’s movements (Kick Counts)
There are many different ways to assess baby’s wellness during pregnancy including ultrasound, non-stress tests, checking fetal heart rate and observing baby’s movement. Mother’s assessment of baby’s movements has been shown to be very predictive of baby’s wellness. You can monitor the health of your baby by counting your baby’s movement each day. It is important to remember that your baby will have times of activity and rest each day. You should choose a time of day that your baby is normally active. Lie down in a quiet place, rest and concentrate on your baby’s movements. Your baby should move at least 6 times in an hour. After an hour you should empty your bladder, have a drink and continue counting for a second hour. If your baby has not moved 6 times within the 2 hours, call your care provider and/or your hospital right away.
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Other times when you should contact your doctor or midwife • If you have any vaginal bleeding with or without discomfort. • If you have regular contractions every five minutes that last more than 45 seconds for more than 1 hour. • If you feel either a gush of fluid or a continual trickle of fluid from your vagina. • If you suddenly develop a severe headache with or without visual disturbances accompanied by heartburn and/or abdominal pain. • If you are sick and/or have a fever for more than 24 hours.
Chapter #18A: Paediatric Services Tools
What will happen when my baby is due?
If labour begins while you have influenza, you should contact your doctor or midwife and plan to go to your hospital as arranged. If possible, telephone the hospital beforehand and tell the hospital staff that you have influenza. Your hospital will have made arrangements for expectant mothers who have influenza. For more information Visit our website at: www.health.gov.on.ca/pandemic INFOline: 1-866-801-7242 TTY 1-900-387-5559 Telehealth: 1-866-797-0000 TTY : 1-866-797-0007
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Diagnosing and Managing Paediatric Influenza This fact sheet provides information for health care providers about signs, symptoms and management of influenza in children during a pandemic. • Myositis is a complication in young Influenza in Children children. • Respiratory illness caused by influenza is Children have the highest attack rates of non-specific in children and can be influenza and could be major disseminators difficult to distinguish from illness of the virus during a pandemic. Although caused by other respiratory pathogens uncomplicated influenza in children may be on the basis of symptoms alone. Many similar to the disease in adults, there are viral infections (respiratory syncytial some age related differences in toddlers and virsus - RSV, human metapneumovirus, infants. parainfluenza, adenovirus, and • Young children usually develop higher rhinovirus), as well as other pyrexial temperatures (over 39.5° C) and may diseases, can cause an illness that is have febrile seizures. clinically indistinguishable from • Unexplained fever can be the only influenza. manifestation of the disease in neonates and infants.
• Influenza viruses are an important cause
•
•
• •
of the common cold, pneumonia, laryngotracheobronchitis (croup), and bronchiolitis in young children. Invasive bacterial infection with respiratory pathogens (i.e., group A streptococcus, Staphylococcus aureus, Streptococcus pneumoniae) can occur with influenza virus infection and cause severe disease. 40 to 50% of young children (mainly occurring in children under age 3) will have gastrointestinal manifestations such as nausea, vomiting, diarrhea, and abdominal pain. Otitis media and non-purulent conjunctivitis occur more frequently in young children. A variety of central nervous system findings, including apnea, opisthotonos, and seizures can occur in a small proportion of infants with influenza. Children may also present with symptoms suggestive of meningitis, such as headache, vomiting, irritability, and photophobia.
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Influenza Symptoms in Children Under 5
The most common presentation of influenza is sudden onset of fever and cough. Young infants (less than 2 months of age) can become ill and progress to severe illness rapidly. They are also much less likely to cough and frequently have only non-specific signs such as poor feeding, apnea, fever or low body temperature. The term acute respiratory illness (ARI) is used to specifically refer to influenza-like illness in young children (less than 5 years of age) since the most distinguishing features in adults are not present until children reach the age of 10. Symptoms of ARI include: • fever (more than 38° C core temperature) • apnea • cough • nasal congestion and/or rhinorrhea • difficulty breathing • tachypnea • hoarse voice • ear ache. Other associated non-respiratory symptoms of influenza in children include: 18A- 12
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• • • • • • •
malaise lethargy lack of interest in toys or play needing extra care poor feeding vomiting or diarrhea general irritability or excessive crying.
Influenza Symptoms in Children Over 5
The most frequent symptoms in children over age 5 and adolescents include fever, chills, cough, non-localized throbbing headache, myalgia, and sneezing. The fever usually ranges from 38 to 40° C, and a second peak, without bacterial superinfection, may occur around the fourth day of illness. Back ache, sore throat, conjunctival burning with watery eyes and epistaxis may be present, but gastrointestinal symptoms are infrequent. Chest auscultation is usually normal but occasionally coarse breath sounds and crackles may be heard. Children at Risk of Influenza-Related Complications
The Canadian National Advisory Committee on Immunization (NACI) considers the following groups of children to be at increased risk for complications from influenza. These include children between the ages of 6 and 23 months, as well as those (of any age) with: • Chronic cardiac or pulmonary disorders (including bronchopulmonary dysplasia, cystic fibrosis, asthma) severe enough to require regular medical follow-up or hospital care. • Chronic conditions such as diabetes mellitus, other metabolic diseases, cancer, immunodeficiency, immunosuppression, renal disease, anemia, or hemoglobinopthay. • Conditions treated with acetylsalicylic acid (e.g., Kawasaki disease, juvenile
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rheumatoid arthritis, acute rheumatic fever) which may increase the risk of Reye’s syndrome after influenza. Signs of Influenza-Related Complications in Children
Children, especially those younger than age 2, are particularly susceptible to complications arising from influenza. Because they may not be able to vocalize their distress, it is critical that healthcare providers are familiar with the symptoms that may suggest influenza-related complications. For children under the age of 5 signs include: • difficulty breathing (i.e. chest indrawing, nasal flaring, grunting, stridor, wheezing, tachypnea) • cyanosis; sudden pallor, cold legs up to the knees • oxygen saturation level of <93% on room air • fever or low temperature • inability to breastfeed or drink • persistent vomiting (more than 2-3 times in 24 hr) • fewer than 4 wet diapers in 24 hours • lethargy or confusion • abnormal sleepiness or difficult to wake • unconsciousness • convulsions or seizures • full fontanelle • stiff neck • photophobia • signs of pneumonia on clinical examination or chest x-ray When these signs are present in infants less than 2 months of age, they suggest severe disease which may be life threatening. Based on their clinical judgment, physicians may chose to refer paediatric patients who present with any of the aforementioned signs and symptoms of influenza on to the
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next level of care (i.e. hospital; emergency department) for further assessment and treatment. In some cases children with uncomplicated influenza infections may be sent home if their condition is sufficiently stable and parents are provided education for managing the child at home.
Table 1: Antiviral Recommendations for Children
Antiviral Agent Oseltamivir
Influenza Antivirals for Children
The indications for provision of antiviral therapy should be based on the recommendations of the Ontario Ministry of Health and Long Term Care at the time of a pandemic. As a guide, however, the following table provides an overview of possible antiviral agents that may be prescribed in select pediatric patients. Currently oseltamivir is the recommended antiviral medication for the treatment of children with influenza over age 1. No antiviral medications are currently approved for use in infants under 1 year of age. The potential for neurotoxicity with oseltamivir in this age group is of particular concern. The mainstay of management for children less than 12 months of age is supportive. Treatment of complications, such as secondary bacterial pneumonia, is essential. Infants less than 12 months of age with severe illness and/or co-morbidities, for whom antiviral therapy is thought to be warranted, should be referred to an infectious diseases expert for careful consideration of such therapy. Similar consultation regarding the potential use of oseltamivir should be sought for pregnant women with severe illness or if the pandemic strain shows spread beyond the respiratory tract.
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Zanamivir
Amantadine
Dose (varies by weight) Weight (Kg.)
Dose
≤ 15 kg
30 mg b.i.d. for 5 days
> 15-23 kg
45 mg b.i.d. for 5 days
>23-40 kg
60 mg b.i.d. for 5 days
>40 kg
75 mg b.i.d. for 5 days
Recommendations
Recommended 1st line therapy for all patients except those <12 months of age, with creatinine clearance <10 l/min, on dialysis, or if pregnant/breast feeding. WARNING: not for use in children <12 months of age.
10 mg (2 inhalations*) b.i.d.
Recommended if creatinine clearance <10 ml/min, on dialysis or pregnant/breast feeding;
*children < age 7 unlikely to perform inhalation effectively.
WARNING: use with caution in patients with reactive airways.
Ages 1-9 dose is 2.5 mg/kg/dose b.i.d. (maximum 150 mg/day)
Recommended 2nd line therapy for nonavian influenza virus infections; not approved for children < 12 months of age.
Ages > 10 years of age & < 40 kg, dose is 2.5 mg/kg/ dose b.i.d. Ages > 10 years of age & > 40 kg, dose is 100 mg b.i.d
WARNING: not recommended for H5N1 strains because of rapid emergence of resistance.
The most common side effects observed in children who are treated with oseltamivir include vomiting, abdominal pain, epistaxis, ear disorder and conjunctivitis. These side effects generally occur once and resolve despite continued dosing in children. There have been some reports of neuropsychiatric adverse events in teenagers using neuraminidase inhibitors, such as oseltamivir, so adolescents should be closely monitored when taking antivirals.
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Influenza Education for Child Care at Home
Children with uncomplicated influenza infections may be sent home, after parents have been advised on the following: • How to maintain hydration • Fever management • Watching for signs of deterioration or failure to improve • A follow-up plan (if necessary) • Immunization or prophylactic treatment of high risk contacts in the household • Infection control practices (i.e., avoiding close contact with others, hand hygiene, respiratory etiquette, etc.) • When to return to the health centre (i.e., if child’s condition worsens; does not feed well; if breathing becomes difficult).
Fact Sheets for Parents and Caregivers
The following fact sheets for parents and caregivers can help support influenza education associated with managing the sick child at home: When your Child is Sick with Uncomplicated Influenza Measuring a Child’s Temperature and Breathing What to do for Fever in Children When to seek medical care for an infant or young child (under age 6) When to seek medical care for older children or adolescents (6-16 years old) For More Information
Visit our website at:
www.health.gov.on.ca/pandemic
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Decision Making Tool for Referral of Pediatric Patients with Influenza-like illness
Influenza Assessment* During an influenza pandemic, children presenting with fever and symptoms suggestive of influenza will require assessment by a practitioner and possible referral to Hospital or to an Influenza Assessment, Treatment and Referral Centre.
Clinical “Red Flags” Cyanosis, pallor; mottled; capillary refill >2 seconds Elevated heart rate Neonate: > 180 beats/ min 1-12 mos: > 160 beats/ min 1-4 yrs: > 130 beats/ min 5-6 yrs: > 120 beats/ min > 6 yrs: > 100 beats/ min • Difficulty breathing (i.e. intercostal indrawing, nasal flaring, grunting, stridor, crackles; wheezes; chest pain) • Elevated respiratory rate < 2 mos: > 60 / min 2-12 mos: > 50 / min NO 1-5 yrs: > 40 / min > 5 yrs: > 30 / min • Extreme lethargy; not interested in toys or playing difficult to wake; Limp or unconscious • Unable to breastfeed or drink effectively • Does not urinate at least every 6 hours Does• the Persistent child have a fever plus any of the following? vomiting (>2-3 times/ 24hrs); feeding poorly • Severe diarrhea • Stiff neck, photophobia • Seizure • Temperature instability (< 35°C; >39°C) • •
Possibly Unstable
High Risk Patients • • • •
Chronic cardiac or pulmonary disease requiring regular medical care Chronic illness such as diabetes, cancer, immunodeficiency, immunosupression Renal disease A condition requiring regular ASA (acetysalicyclic acid)
Consider referral to Hospital for further assessment and treatment
Consider referral to Hospital if clinical status warrants further assessment and treatment Presence of risk factors
Consider Discharge Home with relevant information sheets/ education; antiviral and/ or antibiotic therapy if clinical status warrants
Uncomplicated influenza Consider Discharge Home with relevant information sheets/education; antiviral and/ or antibiotic therapy if clinical status warrants
* Refer to Pediatric Pandemic Influenza Office Assessment Form
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Paediatric Pandemic Influenza Office Assessment Form History & symptoms Fever Chills Sore throat Cough Coryza Stuffy nose Dyspnea Chest pain Myalgia Arthralgia Headache Vomiting Confusion Lethargy Diarrhea ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Underlying medical condition(s) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Medications ____________________________________________________________________________________ ____________________________________________________________________________________ Allergies ____________________________________________________________________________________ * if available
Physical examination o Temp.: _____ C RR ____/min HR ____/min BP ___/___ mmHg Weight ____kg O2 Sat* ____ HEENT_________________________________Genitourinary__________________________________ Respiratory______________________________Skin_________________________________________ Cardiovascular___________________________Musculoskeletal________________________________ Abdomen_______________________________Neurological___________________________________ Disposition (please refer to second page of form for guidelines) Discharge home
Suspected influenza
Yes No
Information sheet(s) provided
When Your Child is Sick With Uncomplicated Influenza Measuring a Child’s Temperature and Breathing What to do for Fever in Children When to Seek Care Over 6 When to Seek Care Under 6
Antiviral therapy
Yes No
Antibiotic therapy
Yes No Agent and dose: _________________________
Follow-up appointment
Yes As needed
Oseltamivir Yes No Dose: _____mg b.i.d. Zanamavir Yes No Dose:10 mg oral inhalation b.i.d. Amantadine Yes No Dose: _____mg b.i.d.
Follow-up in ___________ days
Referred to Hospital for further assessment and treatment Reason for referral ____________________ Physician name Chapter #18A: Paediatric Services Tools
High risk medical condition Clinical features requiring further assessment ______________________ __________________ Signature Date (d/m/y) & Time 18A-17
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Criteria for assessing paediatric patients with suspected pandemic influenza High-risk patients Includes, but is not restricted to, primary or secondary immune deficiency states, malignancy, chronic cardiac, pulmonary (including moderate to severe asthma), renal, liver or neurological conditions, diabetes mellitus. All high-risk patients with significant illness should be referred to a Hospital for further evaluation. Physical examination o
o
Temperature
<35.0 C or >39.0 C
Skin color
Pulse
Neonate: >180 beats/minute 1-12 months: >160 beats/minute 1-4 years: >130 beats/minute 5-6 years: >120 beats/minute >6 years: >100 beats/minute + Systolic BP < 80 + 2*age (years) Symptomatic hypotension
Chest signs & symptoms
BP
RR
Mental status
+Not applicable to neonates or young infants
< 2 months: >60/min 2-12 months: >50/min >12 months to 5 years: >40/min >5 years: >30/min
Hydration
Cyanosis; pallor; mottled; capillary refill > 2 seconds Increased work of breathing; grunting; nasal flaring; intercostal indrawing; crackles, wheezes or dullness to percussion on auscultation; chest pain Lethargic or unconsciousness; confused; irritiability Unable to breast feed or drink effectively; persistent vomiting; feeding poorly
Children with one or more of the above clinical findings should be considered for referral to a Hospital for further assessment; referral may also be considered for children not meeting these criteria but who are thought (based on clinical judgment) to warrant such an assessment. A low threshold for referral is recommended for all children <12 months of age irrespective of clinical status. It is recognized that physicians may choose not to refer selected patients who fulfill one or more of the above criteria based on clinical judgment (i.e. appear well)
Antiviral therapy Indications for antiviral therapy should be based on real time Ministry of Health recommendations Antiviral agents Oseltamivir
Zanamivir
Amantadine
Weight (Kg.) Dose ≤ 15 kg 30 mg b.i.d. for 5 days > 15-23 kg 45 mg b.i.d. for 5 days > 23-40 kg 60 mg b.i.d. for 5 days > 40 kg 75 mg b.i.d. for 5 days 10 mg (2 inhalations) b.i.d. for 5 days
Ages 1-9 dose is 2.5 mg/kg/dose b.i.d. (maximum 150 mg/day)
Recommended as first line therapy for all patients unless <12 months of age, CrCl < 10 ml/min, on dialysis, or if pregnant/ breast feeding WARNING: Oseltamivir should not be used in children <12 months of age* Recommended if CrCl < 10 ml/min, on dialysis or pregnant/breast feeding; children < 7 years of age unlikely to be able to perform inhalation effectively WARNING: Zanamivir should be used with caution in patients with reactive airways A second line agent for non-avian influenza virus infections; not approved for children < 12 months of age* WARNING: Not effective for H5N1 avian influenza
Ages > 10 years of age and < 40 kg, dose is 2.5 mg/kg/ dose b.i.d. Ages > 10 years of age and > 40 kg, dose is 100 mg b.i.d *The mainstay of management for children less than 12 months of age is supportive. Treatment of complications, such as secondary bacterial pneumonia, is essential. Infants with severe illness and/or co-morbidities, for whom antiviral therapy is thought to be warranted, should be referred to an infectious diseases expert for careful consideration of such therapy.
Antibiotics Antibiotic therapy for suspected secondary bacterial pneumonia may be considered in selected cases. The main pathogens that would need to be considered include Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes and non-typable Haemophilus influenzae.
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Paediatric Specific Passive Screening Signage
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Cough and Sneeze Signage
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DRAFT Decision Making Process for Neonatal Intensive Care Patient presents for possible admission to Level II or III Neonatal Intensive Care
Case is reviewed by appropriate triage officer/ team
Decision to admit to Level II or Level III Neonatal Intensive care taking into consideration: Guiding Principles Planning and decision-making within the context of an ethical framework. • Appropriate level of care delivered within principles of safe practice and available resources •
Resource availability Skills and competency based inventory • Alternate care providers considered • Redeployment of staff from other units • Team care models •
Physical Capacity Efforts directed at maximizing physical capacity to provide intensive care services • Establishing “flex” beds •
Admit to Level II or Level III Neonatal Intensive care
Outcome Data Admission based on common, known and transparent parameters with allocation of scarce critical care resources based on best possible outcomes
•
Admit to/remain at non-Level III care
Model of Care The following are examples of care that can and cannot be deferred
Priority A
Priority B
Priority C
Examples of Care that cannot be deferred
Examples of Care that can be deferred for a defined period of time
Examples of Care that can be managed in an alternate way
□ □ □ □ □ □
Care of airway Resuscitation Vital signs monitoring Line insertion/care Wound care Checking bedside resuscitation equipment/crash carts Increase emphasis on cleaning for infection control Isolation Precautions
□
Minimize blood work and procedures based on treatment conditions □ Extend hourly monitoring, vitals and line checks to every 2 hours □ Extend solution changes from every 24 to 48 hours □ Change medication times to □ be delivered with feeds □ Extend time intervals for □ other tubing changes (i.e. vent circuits, inline suction, and IV tubing) □ Consider continuous feeds for infants not at full feeds, no cup/finger feeds □ Nasal/Oral gastric tube Chapter #18A: Paediatric Services Tools replacement weekly or prn
□
□ □ □
□ □ □
□
Hearing screening Bereavement care and support Suspend social, nutrition, teaching rounds (hold only quick interdisciplinary rounds); no social/nutrition/teaching rounds Linen changes and bathing to PRN Daily weights to alternate day or PRN Discharge follow-up managed in community or by phone Bilirubin therapy managed in Level I facility or at home with “bili mat”
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Obstetric Medical Management for Pandemic Influenza Pregnant women – particularly those in the second and third trimester of their pregnancy – are at higher risk of illness, complications and death from pandemic influenza than the non-pregnant population. When managing pregnant women with influenza, practitioners should consider the following.
1. Case Definitions Pandemic Alert During the pandemic alert period, the emphasis is on early detection of cases of novel influenza virus infection. Any symptoms or signs of influenza-like illness (ILI) in conjunction with a possible epidemiologic link to a novel influenza strain should be investigated. Any person with a possible epidemiological link (1.), as described below, PLUS symptoms described in (2.) should be considered a probable influenza case with novel virus infection. 1. Epidemiologic link
a.
Arrival within the last 14 days from a country that has had animal and/or human cases of influenza due to a potential pandemic influenza strain OR
b.
Exposure within the last 14 days to chickens or waterfowl in a region where avian influenza has been documented.
c.
Exposure within the last 14 days to a presumptive or confirmed human case of influenza due to a novel influenza strain.
2. Symptoms
a.
Fever of 38.0º C or higher OR
b.
Respiratory symptoms including cough, stuffy nose or rhinorrhea, sore throat, dyspnea or pleuritic chest pain OR
c.
Otherwise unexplained i. Myalgia OR ii. Diarrhea OR iii. Encephalopathy (defined as a persistent decreased level of consciousness, significant change in personality or behavior or extreme irritability with or without seizures, opisthotonus or apnea).
Pandemic During the pandemic phase, when the pandemic virus is known to be circulating, the emphasis is on identifying symptoms or signs of ILI. The lack of an epidemiologic link cannot be relied upon to exclude the diagnosis. Thus, any person with any of the following symptoms should be considered a possible pandemic influenza case: 1.
Fever of 38.0º C or higher OR
2.
Respiratory symptoms including, but not restricted to, cough, stuffy nose or rhinorrhea, sore throat, dyspnea or pleuritic chest pain.
Note: The case definition may be modified during the pandemic based on observation of clinical symptoms and signs.
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2. Obstetric Pandemic Alert Admission Assessment Admission During the pandemic alert phase all pregnant women meeting the case definition (epidemiologic link AND symptoms) will be admitted, and the case reported to public health. Women will be admitted to either the inpatient unit or ICU depending on clinical status. Admission to the ICU will take place on a case-by-case basis, depending on the patient’s respiratory and overall status, and in consultation with ICU staff. The criteria for admission will be the same that is currently in place. Initial investigations 1.
Routine blood work: blood cultures, CBC with differential, electrolytes, creatinine, urea, glucose
2.
Chest radiograph (AP and lateral)
3.
Microbiology a.
Nasal pharyngeal swabs and throat specimens for conventional respiratory virus detection by IF and culture (i.e. influenza, RSV, parainfluenza, adenovirus) and for other respiratory viruses/agents by PCR (i.e. SARS coronavirus, other coronaviruses, influenza H5, other human and avian influenzas, M. pneumoniae)
b.
Sputum (if possible) or other lower respiratory specimen (i.e. ETT, BAL) for culture and sensitivity
c.
Blood cultures (2 sites)
d. Stool for PCR e.
Serum for PCR
f. CSF for influenza PCR for encephalitis presentation Other possible testing might include B pertussis PCR, lower respiratory specimen for fungal culture, Chlamydia pneumoniae PCR, Legionella pneumophila culture, M. tuberculosis culture and molecular detection. Other testing as indicated clinically, or as knowledge is gained about the specific agent responsible. 4. Fetal non-stress test and/or biophysical profile to assure fetal well-being. Note: as the pandemic evolves, capacity for lab services may become limited. Recommended investigations recommended may have to be reevaluated based on capacity. Management 1.
Isolate if possible.
2.
Use routine practices, appropriate precautions (droplet and contact) and respiratory protection – see Chapter 7).
3.
Consider beginning antiviral treatment (See Section 4).
4.
Maintain adequate hydration. (1/2 normal saline at 125 ml/hr.)
5.
Treat fever above 38.0º C or pain with acetaminophen (1000 mg PO q 6 hours).
Discharge Women will be discharged when they are clinically well AND have been observed for the infectious period of the illness (time to be determined).
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3. Obstetric Medical Management For Pandemic Influenza Admission During the pandemic phase, pregnant women who meet the case definition of pandemic influenza will be evaluated and considered for hospital admission. As more is known about the course and presentation of the pandemic strain, indications for admission may evolve. Because up to one-third of pregnant women may experience pandemic influenza, women with uncomplicated courses of influenza will be managed at home. Pregnant Women with Uncomplicated Pandemic Influenza A. Antepartum Women with Uncomplicated Influenza
1.
Manage at home
2.
Encourage to take antiviral medication (prescribed via telephone, See Section 4)
3.
Encourage to keep well hydrated
4.
Follow their temperatures, to treat fever above 38.0º C or pain with acetaminophen (1000 mg PO q 6 hours)
5.
Perform fetal movement counting once daily (4 kicks in one hour)
6.
Encourage not to come to hospital or clinic unless becoming short of breath, unable to tolerate oral fluids
7.
Encourage frequent telephone consultation.
B. Intrapartum Women with Uncomplicated Influenza
1.
Begin or continue antiviral medication (See Section 4)
2.
Treat fever above 38.0º C or pain with acetaminophen (1000 mg PO q 6 hours)
3.
Maintain hydration (1/2 normal saline at 125 ml/hr)
4.
Use routine practices and appropriate precautions (droplet, contact) – see Chapter 7
5.
Follow usual procedures for intrapartum management.
C. Postpartum Women with Uncomplicated Influenza
1.
Begin or continue antiviral medication (See Section 4)
2.
Treat fever above 38.0º C or pain with acetaminophen (1000 mg PO q 6 hours)
3.
Maintain hydration (1/2 normal saline at 125 ml/hr)
4.
Follow usual standard of care for postpartum management
5.
Continue breastfeeding
6.
Isolate if possible
7.
Use routine practices, appropriate precautions (droplet, contact) and respiratory protection – see Chapter 7
8.
Discharge early if appropriate.
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Pregnant Women with Complicated Pandemic Influenza A. Antepartum Women with Complicated Pandemic Influenza
Hospitalize women who meet the case definition and have one of the following findings: 1.
Unable to tolerate fluids orally.
2.
Have symptoms and signs of respiratory tract infection AND require supplemental oxygen.
3.
Have gastroenteritis AND are unable to maintain hydration with oral fluids.
4.
Have encephalopathy (persistent decreased level of consciousness, significant change in personality or behavior or extreme irritability with or without seizures, opisthotonus or apnea).
5. Look unwell. Admission to the ICU should be made on a case-by-case basis in consultation with ICU staff. If, during the pandemic, new clinical syndromes associated with the infection become apparent, a reassessment of admission and discharge criteria will be necessary for specific presentations. Initial investigations
1.
Routine blood work should include blood cultures, CBC with differential, electrolytes, creatinine, urea, glucose
2.
Chest radiograph (AP and lateral)
3.
Microbiology a. Tests for influenza (pandemic strain) as per microbiology b. Nasal pharyngeal swabs and throat specimens for conventional respiratory virus detection by IF and culture (i.e. influenza, RSV, parainfluenza, adenovirus) and for other respiratory viruses/agents by PCR (i.e. SARS coronavirus, other coronaviruses, influenza H5, other human and avian influenzas, M. pneumoniae) c. Sputum (if possible) or other lower respiratory specimen (i.e. ETT, BAL) for culture and sensitivity d. Blood cultures (2 sites) e. Stool for PCR f. Serum for PCR g. CSF for influenza PCR for encephalitis presentation h. Other possible testing might include (depending on clinical presentation): B.pertussis PCR, lower respiratory specimen for fungal culture, Chlamydia pneumoniae PCR, Legionella pneumophila culture, M. tuberculosis culture and molecular detection. Other testing as indicated clinically or as knowledge is gained about the specific agent responsible.
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Treatment
1. Check airway. Oxygen therapy if saturation below 95% 2. Treat fever above 38.0º C or pain with acetaminophen (1000 mg PO q 6 hours) 3. Maintain hydration (1/2 normal saline at 125 cc/hr) 4. Monitor patient’s intake and output strictly 5. Begin or continue antiviral therapy (see Section 4) 6. Conduct fetal surveillance with daily NST’s and weekly biophysical profiles 7. Isolate if possible 8. Use routine practices and appropriate precautions (routine, droplet, contact) — see Chapter 7. Discharge
Women will be discharged when clinically well. Depending on hospital bed availability, this may be before infectious period is over. B. Intrapartum Women with Complicated Pandemic Influenza Admission to the ICU should be made on a case-by-case basis in consultation with Critical Care Unit staff. Note: if new clinical syndromes associated with the infection become apparent during the pandemic, admission and discharge criteria will be reassessed. Initial investigations
1.
Routine blood work should include blood cultures, CBC with differential, electrolytes, creatinine, urea, glucose
2.
Chest radiograph (AP and lateral)
3.
Microbiology a. Tests for influenza (pandemic strain) as per microbiology b. Nasal pharyngeal swabs and throat specimens for conventional respiratory virus detection by IF and culture (i.e. influenza, RSV, parainfluenza, adenovirus) and for other respiratory viruses/agents by PCR (i.e. SARS coronavirus, other coronaviruses, influenza H5, other human and avian influenzas, M. pneumoniae) c. Sputum (if possible) or other lower respiratory specimen (i.e. ETT, BAL) for culture and sensitivity d. Blood cultures (2 sites) e. Stool for PCR (SARS, influenza H5 or other influenza strains) f. Serum for PCR (SARS, influenza H5 or other influenza strains) g. CSF for influenza H5 PCR for encephalitis presentation h. Other possible testing might include (depending on clinical presentation): B. pertussis PCR, lower respiratory specimen for fungal culture, Chlamydia pneumoniae PCR, Legionella
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pneumophila culture, M. tuberculosis culture and molecular detection. Other testing as indicated clinically or as knowledge is gained about the specific agent responsible. Treatment
1.
Check airway. Oxygen therapy if saturation below 95%.
2.
Treat fever above 38.0 C or pain with acetaminophen (1000 mg PO q 6 hours).
3.
Maintain hydration. (1/2 normal saline at 125 cc/hr.)
4.
Monitor patient’s intake and output strictly
5.
Begin or continue antiviral therapy. (See Section 4.)
6.
Monitor fetus continually
7.
Continue standard protocols for intrapartum management and care
8.
Isolate if possible.
9.
Use routine practices, appropriate precautions (droplet, contact) and respiratory protection — see Chapter 7.
Discharge
Women will be discharged when clinically well. Depending on hospital bed availability, this may be before infectious period is over. C. Postpartum Patient with Complicated Pandemic Influenza Admission to the ICU should be made on a case by case assessment as is done currently. Initial investigations
1.
Routine blood work should include a blood cultures, CBC with differential, electrolytes, creatinine, urea, glucose
2.
Chest radiograph (AP and lateral)
3.
Microbiology a. Tests for influenza (pandemic strain) as per microbiology b. Nasal pharyngeal swabs and throat specimens for conventional respiratory virus detection by IF and culture (i.e. influenza, RSV, parainfluenza, adenovirus) and for other respiratory viruses/agents by PCR c. Sputum (if possible) or other lower respiratory specimen (i.e. ETT, BAL) for culture and sensitivity. d. Blood cultures (2 sites) e. Stool for PCR. f. Serum for PCR g. CSF for influenza PCR for encephalitis presentation. h. Other possible testing might include (depending on clinical presentation): B. pertussis PCR, lower respiratory specimen for fungal culture, Chlamydia pneumoniae PCR, Legionella pneumophila culture, M. tuberculosis culture and molecular detection. Other testing as indicated clinically or as knowledge is gained about the specific agent responsible.
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Treatment
1.
Check airway. Oxygen therapy if saturation below 95%.
2.
Treat fever above 38.0 C or pain with acetaminophen (1000 mg PO q 6 hours).
3.
Maintain hydration. (1/2 normal saline at 125 cc/hr.)
4.
Monitor patient’s intake and output strictly
5.
Begin or continue antiviral therapy. (See Section 4.)
6.
Monitor baby continuously
7.
Continue standard protocols for intrapartum management and care
8.
Isolate mother and child if possible.
9.
Use routine practices, appropriate precautions (droplet, contact) and respiratory protection — see Chapter 7.
Discharge
Women will be discharged when clinically well, which may be before the infectious period is over.
4.
Antiviral Medication Recommendations for Pregnant Women with Pandemic Influenza
Antiviral medications and influenza immunization will be available to reduce illness and death secondary to pandemic influenza (1). Once available, a vaccine will be a vital component of the public health response to pandemic influenza and should be given to pregnant women, as they are at increased risk for complications related to pandemic influenza. Inactivated influenza vaccine is recommended annually to pregnant women. Several reports have demonstrated the safety of the inactivated vaccine in all trimesters in pregnancy. During a pandemic, immunization would be a vital intervention. Both human and animal studies suggest that hyperthermia is associated with an increased risk of adverse effects, such as an increased risk of neural tube defects(2,3). Any time a woman becomes pregnant, she has a 1 to 3% chance of having a baby with a birth defect. Fever associated with influenza can increase the risk of teratogenicity, so pregnant women should be counseled to treat fever aggressively during a pandemic. There will be many medications used in the non-pregnant population during the pandemic, most of which will lack safety evidence in pregnancy. In the event of a pandemic, the theoretical risk of teratogenicity and adverse effect of treatment will have to be weighed against the potential benefit to the pregnant woman with influenza. It is recommended that, during a pandemic, pregnant women take antiviral medication if they become ill. The following guidelines will help with decision-making when using antiviral medication in the setting of pandemic influenza. *As pregnant women are at increased risk for complications secondary to pandemic influenza, treatment with a neuraminidase inhibitor should begin within 48 hours of the onset of influenza symptoms, preferably within 12-24 hours.
Chapter #18A: Paediatric Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Antiviral Medication The neuraminidase inhibitors are the antiviral medications most likely to be used during an influenza pandemic. Early treatment with neuraminidase inhibitors decreases the risk of hospitalization, complications and death from influenza. Both of the following drugs can be used to prevent or treat influenza A or B. • *Oseltamivir (Tamiflu®): Oral therapy. • *Zanamivir (Relenza®): Inhaled medication. Zanamivir may be preferred in pregnant women, as systemic blood levels are comparatively lower than oseltamivir. (5,6) However, if systemic viral replication is thought to occur with the novel or pandemic virus, oseltamivir would be preferred, as it has higher bioavailability outside of the respiratory tract. (7,8) Risk of Teratatogenicity
There have been no published reports of pregnancy outcomes following treatment with antiviral medications(4). It is reassuring that animal studies on oseltamivir and zanamivir have not raised any concerns during pregnancy. As data are limited, we cannot be completely reassured that these medications are safe in pregnancy; however, animal studies suggest that they would not be associated with a significantly increased risk of birth defects. The M2 ion channel blockers amantadine and rimantidine are currently not recommended due to potential risk of adverse effects, current high rates of resistance to these medications among human influenza A virus and some avian influenza viruses (1), and the rapid emergence of resistance during treatment. Breastfeeding
As little zanamivir is absorbed or found in breastmilk, it is the preferred drug for women who are breastfeeding; however, no safety data is available. Likewise, there is no information on the safety of taking oseltamivir while breastfeeding, and it is not known if the drug is excreted in human milk. Once again, the risk vs. benefit ratio will have to be evaluated on an individual basis. Dosing
Prophylaxis for pandemic influenza: Drug
Adult Dose
Route
Duration
Oseltamivir
75 mg once daily
PO
10 days
Zanamivir
10 mg (two inhalations) once daily
oral inhalation
10 days
Chapter #18A: Paediatric Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
Treatment for pandemic influenza: Drug
Adult Dose
Route
Duration
Oseltamivir
75 mg once daily
PO
5 days
Zanamivir
10 mg (two inhalations) twice daily
oral inhalation
5 days
Antibiotic therapy for suspected secondary bacterial peumonia a. General consideration
•
Other potential causes of pneumonia, such as non-influenza respiratory viruses, Mycoplasma pneumoniae, and Streptococcus pneumoinae should be considered in all pregnant women admitted with suspected pandemic influenza
b. Common organisms implicated in secondary bacterial pneumonia
•
Streptococcus pneumoniae
•
Staphylococcus aureus
•
Non-typable Haemophilus influenzae
c. Antibiotic choice in pregnant women with secondary bacterial pneumonia
•
Cefuroxime is expected to be the most widely used antibiotic due to its coverage of most strains of Streptococcus pneumoniae, non-typable Haemophilus influenzae and Staphylococcus aureus
•
Women with severe beta-lactam allergy (anaphylaxis) should be given vancomycin or clindamycin
Supportive therapies
•
Bronchodilators
Corticosteroids
Other experimental therapies: •
Intravenous immune globulin
•
Interferon (generally not in pregnancy)
•
Anti-TNFα (generally not in pregnancy)
Chapter #18A: Paediatric Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
References: 1.
Rasmussen SA, Jamieson DJ, Bresee JS. Pandemic influenza and pregnant women. Emerging Infectious Diseases. www.cdc.gov/eid.vol. 14,No.1,January 2008.
2.
Edwards MJ. Review: hyperthermia and fever during pregnancy. Birth Defects Res A Clin Mol Teratol. 2006;76:507-16.
3.
Moretti ME, Bar-Oz B, Fried S, Koren G. Maternal hyperthermia and the risk for neural tube defects in offspring: systematic review and meta-analysis. Epidemiology. 2005;16:216-9.
4.
OTIS. Antiviral medications to treat/prevent influenza (flu) and pregnancy. Dec. 2005. www.OTISpregnancy.org
5.
Allen UD, Aoki FY, Stiver HG. The use of antiviral drugs for influenza: Recommended guidelines for practitioners. AMMI Canada Position Paper. Can J Infect Dis Med Microbiol. 2006; 17: 273-84
6.
Ward P, Small I, Smith J, Suter P, Dutkowski R. Oseltamivir (Tamiflu) and its potential for use in the event of an influenza pandemic. J Antimicrob Chemother. 2005;55(Suppl 1):i5-21.
7.
WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus. Lancet Infect Dis 2007; 7: 21-31
8.
Freund B, Gravenstein S, Elliott M, Miller I. Zanamivir: a review of clinical safety. Drug Saf. 1999;21:267-81.
Contributions by: S. Mahant, A. Bitnun, R.Tellier, K. Murphy, M. Sermer.
Chapter #18A: Paediatric Services Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
DRAFT: Preparation for Discharge – Uncomplicated Vaginal Birth Date: ________________________
Time: _______________________
Maternal Outcomes
Vital Signs within normal limits: Temperature less than or equal to 37.5°C Pulse between 60-100 beats per minute Blood Pressure < 140/90 (specify): _____________ Fundus Midline, firm at or below umbilicus Perineum Suturing intact Minimal edema, bruising Hemorrhoids may be present Lochia Moderate rubra or less Elimination Voiding sufficient amount No bladder distention Breast Feeding Mother able to latch baby to breast Pain Maternal pain controlled with oral analgesics Rh Immune Globulin Mother’s blood group (specify): _____________ Baby’s blood group (specify): _____________ IM given if patient is Rh negative & Baby is Rh positive or stillbirth Additional dosage if required (under advice of Transfusion Medicine based on fetal cell screen) Care Mother able to verbalize/ demonstrate care for self If no, specify reason: _________________________________________ Mother able to verbalize/ demonstrate care for newborn If no, specify reason: _________________________________________
Baby Outcomes
Time of birth: _____________ Weight: _____________ Skin Colour: _____________
Apgar score: _____________ Length: _____________ Axillary Temperature 36.5° to 37.5°C
Vitamin K given Newborn Screening done Other (specify): ______________________ Urine/Bowels Umbilical Cord Feeding/Breastfeeding Baby observed successfully latching to breast Other (specify): __________________________________________
Teaching Completed
Postpartum care & safety Feeding/Breastfeeding
Breast changes
Fundus levels
Bleeding (normal versus abnormal)
Urine/Bowels
Pain management
Sleep
Nutrition
Signs of wellness; exercise Postpartum depression Other (specify): __________________________________________ Infant Care Urine/Bowels
Feeding/Breastfeeding
Umbilical Cord Care
Skin Care
Signs of illness
Sleep positions
Other (specify): __________________________________________
Chapter #18A: Paediatric Services Tools
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DRAFT: Early Discharge Postpartum Follow-up Guidelines Telephone call Visit (within 24 hours of discharge)
Maternal Assessment
Signs/ symptoms of fever Temperature less than or equal to 37.5°C Perineum/Incision
Fundus Lochia Voiding/Stool Pain Breasts Rest/Sleep Activity Nutrition Coping Skills/Support Newborn Assessment
Teaching
(within 48 hours of discharge)
Vital Signs including BP Examination Perineum/Incision Assess Fundus Assess Lochia Voiding/Stool Pain control Examine Breasts Rest/Sleep Activity Nutrition Coping Skills/Support
Feeding (breast/ bottle)
Feeding (breast/bottle) frequency
frequency (specify):______________ Skin colour (signs & symptoms of
(specify):______________
jaundice)
jaundice)
Skin colour (signs & symptoms of
Voiding/Stooling frequency Activity (awake/sleep patterns;
Voiding/Stooling frequency Activity (awake/ sleep patterns;
crying)
crying)
General mother & baby care Baby safe sleeping positions Signs & Symptoms of Jaundice Feeding/Nutrition Fundus Levels Void/Stool frequency Car seat safety Postpartum depression/mood
General mother & baby care Baby safe sleeping positions Signs & Symptoms of Jaundice Feeding/Nutrition Fundus Levels Void/Stool frequency Car seat safety Postpartum depression/mood
disorders signs & symptoms
disorders signs & symptoms
Newborn Screening
Intervention
(specify):______________
Bilirubin
(specify):______________
Weight
(specify):______________
Other (specify):________________________
Follow-up Required
Postpartum visit
Additional Postpartum visit
(specify date/ time):______________
required
Urgent MD visit Breast feeding support/ assessment
Chapter #18A: Paediatric Services Tools
(specify date/ time):______________
MD appointment Medical referral Community health referral
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Alternate Model of Prenatal Care during a Pandemic This fact sheet provides information on a model to manage low risk prenatal care during a pandemic that uses a combination of caregiver visits at critical times in the pregnancy and education/telephone support to engage the healthy pregnant woman in her own self-care. Prenatal Care during a pandemic
Third Trimester With the pregnancy approaching viability, women should be taught how to assess fetal wellness by monitoring baby’s movements and be given written information about pregnancy complications such as bleeding, preterm labour and pregnancy induced hypertension.
Any model of prenatal care designed to address the needs of pregnant women during a pandemic should consider ways to avoid maternal exposure to influenza while ensuring maternal/fetal wellness. Any woman who is pregnant or becomes pregnant during an influenza pandemic should contact her obstetrical care provider to discuss a plan for her prenatal care.
Schedule a final clinic visit at 40 weeks gestation to discuss and develop a plan for birth.
Prenatal Assessment
Use regular telephone contact to discuss the woman’s self assessment of weight gain, blood pressure, urine analysis and fetal movement as well as any maternal concerns.
Defer prenatal care during the first trimester until 10 to 12 weeks gestation. At that time, take a comprehensive history, do a physical and laboratory assessment, and assign a risk category, as per the Ontario Antenatal 1, Guide for Pregnancy Risk Assessment, to the pregnancy. If resources are available, offer the first trimester biochemical screening and a nuchal translucency assessment. If resources are not available for integrated screening, obtain a first trimester ultrasound and make arrangements for maternal serum screening between 16 and 18 weeks gestation. Use this visit to discuss pregnancy care and teach women how to monitor their own well-being, including serial weight, blood pressure assessment and urine analysis. Second Trimester Schedule the second prenatal visit between 18 and 20 weeks gestation, scheduling an anatomy scan to take place immediately before the prenatal assessment. Use the information from the anatomy scan as well as the results of tests performed at the initial visit to review the pregnancy to date and reconfirm or revise the pregnancy risk status.
Chapter #18A: Paediatric Services Tools
Telephone Follow-up Follow women with no identifiable pregnancy risk through telephone contact every 4 weeks until 32 week gestation, every 2 weeks until 36 weeks and weekly until their expected date of delivery.
High Risk Pregnancy Prenatal care for women at risk for pregnancy complications would require a more complex process. The basic principles of protecting the woman from exposure and engaging her in self-care could still be used, but more frequent provider visits may be indicated. For more information The Pandemic Influenza and Pregnancy fact sheet provides information on how to test urine, measure blood pressure and monitor baby movement; describes signs and symptoms; and outlines when to seek medical attention if pregnant or beginning labour with influenza. Visit our website at: www.health.gov.on.ca/pandemic INFOline: 1-866-801-7242 TTY 1-900-387-5559 Telehealth: 1-866-797-0000 TTY : 1-866-797-0007
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19. Long-Term Care Homes Influenza almost always selects the weakest in society to kill, the very young and the very old. … Pneumonia was even known as “the old man’s friend” for killing particularly the elderly, and doing so in a relatively painless and peaceful fashion that even allowed time to say good-bye. The Great Influenza, John M. Barry
If an influenza pandemic does occur in Ontario, residents in long-term care homes (LTCHs) may be affected. Viruses can be introduced into LTCHs by staff and visitors, and they can spread easily in these closed communities. Because of their age and underlying medical conditions, most people living in LTCHs who develop influenza are at increased risk of complications. During seasonal influenza outbreaks in LTCHs, up to 70% of residents and staff may become infected. Based on an attack rate of 35% at the peak period of a pandemic wave, between 20 to 25% of LTCH home staff may fall ill and be unable to work for a period of time. LTCHs across Ontario already have emergency plans and infection prevention and control programs in place to prevent and manage respiratory infection outbreaks, including seasonal influenza (see A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes at: http://www.health.gov.on.ca/english/ providers/pub/pubhealth/ ltc_respoutbreak/ltc_respoutbreak.html. This chapter, which is designed to supplement the guide, provides information on how to plan for specific issues that may arise during an influenza pandemic. If an influenza outbreak occurs in the home during the pandemic, LTCHs should use both the guide and the information in OHPIP.
Chapter #19: Long Term Care
19.1 Objectives • To help long-term care homes prepare for a pandemic.
• To reduce the spread of pandemic influenza within LTCHs among residents, staff, family members and volunteers.
• To maintain essential care and services for residents during a pandemic in order to keep them in the LTCH.
• To make effective use of staff skills and knowledge during a pandemic.
• To identify services in LTCHs that can be reduced, modified or curtailed during a pandemic.
• To ensure that workplace health and safety standards are maintained to support staff, families and volunteers in meeting resident care and service needs.
19.2 Planning To prepare for an influenza pandemic, LTCHs should develop their own plans and coordinate them with other health organizations in their community, public health unit area or Local Health Integration Network (LHIN). Develop a Pandemic Influenza Plan Every LTCH should establish a pandemic planning team and a coordinator responsible for pandemic planning. The planning team should include people with expertise in infection prevention and control, and develop plans in collaboration 19- 1
Ontario Health Plan for an Influenza Pandemic August 2008
with the LTCH’s Joint Health and Safety Committee or Safety representative. The LTCH should also work closely with longterm care compliance inspectors in developing and implementing their pandemic plans. Inspectors are a valuable resource for planning. The LTCH’s pandemic plan should be reviewed and updated annually or more frequently if required. These plans should augment the LTCH’s outbreak management and emergency plans.
from LTCHs how will LTCH provide care? Can well residents be moved to another site/level of care? How will the system make the best use of human resources?)
• identify agencies that could provide staff in the event of shortages (e.g., nursing agencies)
• identify volunteers or family members who could provide services or assistance in the event of a shortage of trained staff
• work with partners, such as acute care Review and Update Emergency Plans Because an influenza pandemic is likely to cause social disruption and affect critical services, LTCHs should review their emergency/business continuity plans to ensure they take into account the potential impact of an influenza pandemic. Coordinate Planning with Other Health Organizations Because an influenza pandemic will affect the whole community, LTCHs cannot plan in isolation. They should:
• connect with other health organizations in the community, including the public health unit (which has lead responsibility for local pandemic planning), other LTCHs, hospitals, community care access centres (CCACs), home care providers, primary care providers, emergency medical services (for resident transfers), laboratory services, pharmacies and regional infection control networks
• familiarize themselves with other organizations’ plans and functions during a pandemic
• identify opportunities to collaborate/ share resources during a pandemic
• identify possible scenarios and how they would be handled by the system (e.g., if the hospital is unable to accept residents
Chapter #19: Long Term Care
hospitals and CCACs, to determine how to apply provincial criteria (to be developed) for who will be admitted to hospital, cared for in a LTCH, and/or served by home care.
19.3 Options for Resident Care LTCHs should assess residents’ care needs in order to identify, in the event of pandemic influenza in the community or home:
• residents who could be discharged temporarily to family members
• residents who could be discharged temporarily home with home care services
• residents who must continue to be cared for in a LTCH. This information will be particularly important if hospitals are overwhelmed and LTCH beds are needed for influenza patients convalescing, or in the event of staff shortages.
19.4 Services to be Reduced, Enhanced or Deferred During a pandemic, LTCHs may reduce or delay some services to compensate for staff shortages, or to prevent the spread of influenza. Table 19.1 provides examples of 19- 2
Ontario Health Plan for an Influenza Pandemic August 2008
services that could be reduced, deferred or enhanced, based on severity of the pandemic and residents’ needs.
health unit.
Onsite adult day programs or childcare programs may be reduced or curtailed based on the capacity of the LTCH to staff them or due to public health measures implemented by the local Medical Officer of Health. As long as homes have enough staff, they can continue to provide these programs – unless instructed otherwise by the local public health unit. There should be no interaction between ill residents and program participants. Program participants should be screened for ILI before entering the home.
It is unlikely that the spread of a pandemic strain into Ontario will first be detected in a LTCH but, because residents are highly vulnerable, the pandemic virus could spread quickly and easily from the community into the long-term care environment. Surveillance is a key component of detecting, preventing and managing the spread of pandemic influenza. Someone with training in infection prevention and control should be responsible for the home’s surveillance program.
Decisions about which services to reduce, curtail or enhance should be made based on nursing and professional judgment, residents’ needs, infection control and prevention guidelines, and advice from the public health unit. Plans to reduce services should be discussed with public health and compliance inspectors and the College of Nurses. Note: some laboratory services may be curtailed during a pandemic, and this may affect the routine care and diagnosis services that LTCHs provide (see Chapter 14). Managing a Potential Increase in Deaths Depending on the severity of pandemic strain, LTCHs may see an increase in deaths. Most LTCHs do not have morgues or systems for storing or removing multiple bodies. For information on how to manage this situation, please see the Ministry of Community Safety and Correctional Services Natural Death Surge Capacity Plan. LTCHs can also contact their local public
Chapter #19: Long Term Care
19.5 Surveillance
LTCHs already do regular surveillance for febrile respiratory infections. When pandemic activity has been reported in the community (phase 6), LTCHs should enhance their surveillance. During a pandemic, LTCHs should:
• continue to monitor residents for signs of FRI/ILI
• conduct active surveillance for FRI/ILI in visitors, students, staff and new residents
• continue to take nasal pharangeal swabs during a respiratory infection outbreak during a pandemic, but not as many
• notify the local medical officer of health of any respiratory infection outbreak in the home
• continue to report daily line listings to the health unit, but submit the aggregate information electronically using the web portal (for more information, see Chapter 5: Surveillance).
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Table 19.1: DRAFT FOR DISCUSSION ONLY: LTCH Services that Could be Maintained, Reduced or Enhanced During an Influenza Pandemic (adapted from Peel Long-Term Care Pandemic Influenza Plan) Type of Service
Level of Care that Must be Maintained
Personal care
Face, hands and perineum washed twice daily and as needed to maintain skin integrity Active care that reduces risk of health complications
Medications
Administered as prescribed
Personal hygiene and grooming
Services that May be Enhanced
Bathing limited to baths/showers as needed
Antiviral administration Modify depending on resident health needs, staff availability; defer care of fingernails and feet
Oral Care
Twice daily
Assessment of care needs
Ongoing
Frequency may be reduced As needed
Clothing and bedding changes Toileting and incontinence care
Services that Could be Reduced
Maintain routine toileting and incontinence care Maintain routine catheter care as ordered
Skin and wound care
Routine aseptic dressings, sterile dressings and colostomy care
Assistance with eating
Provide as needed
Oxygen therapy
Maintain
Maintain G-tube feeding
Repositioning bedridden residents Communications with families/ decision makers
Once every 2 hours or as needed to promote comfort and prevent skin breakdown Maintain regular communications Reschedule
Non-urgent medical appointments Contract services
May have to increase frequency or change method (e.g., website)
Determine whether services such as physiotherapy and psychiatry visits should continue
Defer hairdressing and foot care depending on resident needs (i.e., foot care not deferrable for residents with diabetes)
Day programs
Defer and reschedule, depending on resident health needs, staff availability and severity of pandemic
Social and recreational activities
Can be reduced or deferred
Management of natural deaths
Chapter #19: Long Term Care
Will likely increase
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Ontario Health Plan for an Influenza Pandemic August 2008
19.6 Human Resource Planning Human resources planning is key to maintaining services during a pandemic. LTCHs should work with the Medical Directors and attending physicians, nurse practitioners and others to plan for the delivery of critical or acute care technical services such as starting intravenous therapy, oxygen support and ordering laboratory tests (as outlined in chapter 14). To ensure continuity of physician services, some communities might establish a group of two or three physicians who will provide telephone support to all LTCHs or provide care to all residents in a certain number of LTCHs (i.e., doctors on wheels). During a pandemic, LTCHs are likely to experience staff shortages, and may have to take extraordinary measures to continue to provide care for residents. OHPIP supports a skills-based approach (for more information, see competency evaluation tools in Chapter 8). As part of their planning, LTCHs should identify:
• the minimum skills required to meet residents’ needs, including providing care for residents who develop influenza
• the direct care staff who have those skills or who could be trained to take on more responsibilities within their scope of practice in different roles
• strategies that could be used to increase capacity (e.g., contracting staff from external agencies, extending working hours, calling staff back to work)
• other staff (e.g., clerical, housekeeping) who could be trained to assist with care (e.g., feeding of residents who are not at high risk of choking)
Chapter #19: Long Term Care
• family members/volunteers who could be trained to help with care and daily living activities (e.g., how to give a bed bath and assist with feeding and toileting)
• staff /volunteers with skills to provide training to family members and volunteers
• other organizations in the community that might be able to provide workers with the appropriate skills
• any labour (i.e., union), insurance or liability issues the LTCH would have to address if it altered staff roles or used temporary workers and volunteers
• which staff will be responsible for supervising staff in different roles, family members or volunteers who participate in resident care delivery
• the supports that staff and other workers may need to be able to work (e.g., transportation, accommodation, assistance with child care and other family responsibilities). LTCHs should engage members of the Occupational Health and Safety Committee and the union (i.e., the bargaining agent) in pandemic planning to ensure that their plans include appropriate practice, communication and education.
19.7 Infection Prevention and Control Measures For Staff and Volunteers Information on occupational health and safety and infection prevention and control is set out in detail in Chapter 7, and include both the hierarchy of controls approach to create a safer work environment, and the use of routine,
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droplet and some airborne precautions. The type of personal protective equipment required is also described in that chapter. The differences from usual practice in a LTCH during a pandemic include:
• the use of N95 respirators by everyone entering a room where there are residents with influenza-like illness
• the recommendation to cohort residents with pandemic influenza, depending on the capacity/structure of the home, the nature of the home’s population (i.e., will moving people be too disruptive), and the severity and epidemiology of the pandemic strain
• if cohorting is not possible, separating residents who are particularly vulnerable to complications from influenza from residents with influenza
• restricting residents with influenza to their rooms as long as it does not cause the resident undue stress or agitation and can be done without applying restraints
• screening all new admissions to the home during a pandemic
• the importance of following the established transfer authorization process when transferring patients to hospital or to another health care facility – unless other arrangements have been made for transfers during a pandemic (i.e., Fax PTAC at 416-3979061 for a transfer request, or use the web-based application if available. If approved, an authorization number will be issued immediately and faxed or issued on-line to the home)
• allowing ill staff, students and volunteers to return to work before they are completely recovered (if
Chapter #19: Long Term Care
required because of staff shortages), but restricting ill workers to non-direct care or to working with residents with symptoms of ILI if possible. Staff, students and volunteers should NOT be deployed to care for high risk, medically fragile patients
• there will be few restrictions on where staff are allowed to work because the virus will be widely circulating in the community. If there are significant staff shortages throughout the health care system, staff may work in many different settings.
Occupational Health and Safety Tip Box Employers shall develop and implement appropriate measures, procedures and training for the protection of workers in consultation with Joint Health & Safety Committees (JHSC) or Health and Safety Representatives and Infection Prevention and Control resources. See measures in Chapter 7 for more information. Some examples of controls in long-term care settings include: HVAC system hand hygiene and cough etiquette signage barriers (e.g., curtains, Plexiglas) education and training for workers and supervisors appropriate IPC housekeeping practices by trained workers personal protective equipment (based on risk assessment) For more advice on identifying and implementing controls, see the following web sites: http://www.labour.gov.on.ca; http://www.ricn.on.ca; http://www.osach.on.ca; http://www.whsc.on.ca For more information on Occupational Health and Safety Measures and Infection Prevention and Control in Health Care Settings consult the OHPIP Chapter 7.
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For Volunteers Visitors will likely not be restricted from the LTCH unless they are ill because they will be needed to assist with care. During a pandemic, visitors should be required to perform hand hygiene on arrival, before leaving the resident’s room, and before leaving the LTCH, and use PPE as instructed by staff. Any restrictions on visitors should be based on the severity and epidemiology of the pandemic; however, not allowing visitors is not recommended, as it may cause emotional hardship to both the residents and the relatives. Notices should be posted on the doors of rooms of ill residents advising visitors to check at the nursing station before entering the room.
19.8 Outbreak Management If an outbreak of influenza is detected in the LTCH during the pandemic, the LTCH should follow the recommendations of the Ministry of Health and Long-Term Care document: A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes. In addition, the LTCH should take into account the following:
• there are some differences in infection control (see 19.7), such as the use of N95 respirators
• antivirals will be used for all staff, volunteers and residents for outbreak control if pandemic vaccine is not yet available
• exclusion policies for unvaccinated staff will not apply if there is no vaccine available for the pandemic strain
• it is unlikely that public health units will be able to offer on-site assistance
• outbreak reporting has been
based surveillance system (see Chapter 5: Surveillance); however, line listings should still be sent to the public health unit
• the importance of reporting if an outbreak fails to come under control with the use of antivirals and taking additional swabs to check for antiviral resistance or other organisms.
19.9 Education and Staff Support Preparedness should include ongoing education of staff, volunteers, residents and residents’ families about influenza and the home’s pandemic plan. A significant amount of education will focus on infection prevention and control practices and measures to protect the health of staff and residents (see Chapter 7). Education plans should be developed in collaboration with staff responsible for occupational health and safety. They should include:
• the education required for staff, including staff who do not routinely care for residents but might have to during a pandemic
• education for volunteers • education required for residents, the Residents’ Council, families and the Family Council, which may include training family members to assist with some aspects of care during a pandemic (e.g., bed baths, assisting with feeding and toileting)
• education for visitors • approaches to training (e.g., teambased approaches that will ensure any temporary workers receive appropriate support and supervision, and crosstraining to ensure staff are able to
streamlined and will use the webChapter #19: Long Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008
cover one another’s duties, such as peritoneal dialysis)
• frequency of training (e.g., during orientation, then annually – or more frequently if threat of a pandemic is imminent)
• training resources (e.g., pamphlets, fact sheets, formal presentations, public awareness campaigns). Every effort should be made to ensure that education provided by the LTCH is consistent with that provided by other homes and other health care organizations in the community and province. Education Programs Education and training programs for all staff and residents should include (but not be limited to):
• the home’s influenza pandemic plan • the importance of hand hygiene and proper hand hygiene technique
• appropriate cleaning and disinfection of equipment (i.e., any equipment that is shared between residents must be cleaned and disinfected after each use)
• individual staff responsibility to keep other staff and residents safe
• the employers’ responsibility to protect workers health
• any changes to staff exclusion policies during a pandemic and the reasons for those changes. Supporting Staff LTCHs should work with unions to identify supports that will help staff provide care during a pandemic such as:
• assistance with transportation • accommodation and meals • access to counselling and psychosocial support to help staff cope with jobrelated stress or with anxiety about the pandemic
• flexible scheduling that gives staff time to fulfill family responsibilities with family-related needs
• assistance with babysitting for children (i.e., if schools are closed or staff are working extra shifts), caring for elderly family members, and caring for pets. See also Chapter 21, Psychosocial Support.
• appropriate use of PPE which includes application, removal and disposal of gloves, gowns, eye protection, surgical masks and N95 respirators
• risks associated with infectious diseases such as febrile respiratory illnesses (FRI) – including influenzalike illness (ILI)
• benefits of case finding/surveillance • principles and components of routine infection control practices
• risks of transmission • procedures that are considered high
19.10 Antivirals and Vaccine During a pandemic, LTCHs will be responsible for administering antivirals to residents and staff, for treatment and outbreak control. Once a vaccine is available, LTCHs will also be responsible for immunizing residents, staff and volunteers. The Ministry Emergency Operations Centre (MEOC) will be responsible for supplying and coordinating the distribution of antivirals to LTCHs, and the public health unit will be responsible for supplying and coordinating the distribution of vaccine.
risk and the reasons for that risk
Chapter #19: Long Term Care
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Ontario Health Plan for an Influenza Pandemic August 2008 Administration of Antivirals
Antivirals will be supplied to LTCHs as needed, based on available supplies and demand in the community. LTCHs may make arrangements (e.g., a service agreement) with the pharmacy affiliated with the LTCH to assist in dispensing and administering antivirals. LTCHs must have the capacity to safely store antivirals and vaccine, including cold chain storage that meets public health guidelines (i.e., keeps vaccine at a temperature between 2 and 8º C) and maintain distribution records. LTCH pandemic plans should:
• identify the person responsible for receiving, storing and reporting on the use of antivirals and vaccine
onset of symptoms – preferably within 12 to 24 hours. Antivirals can be prescribed up to 48 hours after onset of symptoms, but they will be less effective. Treatment decisions are the responsibility of attending physicians but, because it may be difficult to reach attending physicians during an influenza pandemic, LTCHs should have medical directives and consent forms on file that allow them to administer antivirals to residents who are ill with ILI. Use of Antivirals for Prophylaxis A provincial policy for the use of antivirals during an influenza pandemic will be developed when national recommendations are complete. This section will be updated then.
• identify where antivirals and vaccine will be stored, and how the home’s supply will be kept secure
• review security procedures to ensure they are adequate
• have a contingency plan in case of power failure or equipment malfunction
• set out the role of the pharmacy on contract with the LTCH in providing access to antivirals and backup services (if any)
• describe the mechanisms the LTCH will use to track who receives antivirals and vaccine, and to report any adverse reactions. (For more information on the storage and distribution of antivirals and vaccine, see Chapter 9A: Ontario Emergency Mass Vaccination/Prophylaxis Plan.) Prescribing and Administering Antivirals To be most effective, antiviral treatment must be started as soon as possible after Chapter #19: Long Term Care
19.11 Supplies and Supply Chains As part of preparedness planning, LTCHs should identify the type and quantity of supplies (other than antivirals and vaccine) they will need, and purchase and maintain a one-month stockpile. MOHLTC will also maintain a one-month supply for LTCHs. See Chapter 10 for a supplies and equipment template developed by the Ministry of Health and Long-Term Care. During a pandemic, traditional supply chains may be disrupted. For example, a supplier in another jurisdiction may have to give priority to local companies. During the preparedness phase, LTCHs should:
• talk to suppliers about their ability to deliver during a pandemic
• review systems in place to ensure adequate supplies (e.g., environmental cleaning supplies, food, medications, oxygen concentrators)
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• establish relationships with alternative suppliers/sources, including: equipment suppliers, food suppliers, medical suppliers, pharmacies, oxygen suppliers, attending physicians and any other health care providers who provide contracted services to the home (e.g., physiotherapists, occupational therapists).
19.12 Communication Most LTCHs will already have plans and procedures for communicating with residents, residents’ families, staff, media and other organizations in the community (e.g. local public health units, the coroner’s office, and funeral directors) in the event of an outbreak or emergency. These plans should be reviewed to ensure that they will be appropriate during a pandemic. To provide effective communications, LTCHs should:
• use other communication systems as appropriate (e.g., website) to maintain communications with family members and visitors.
19.13 Review the Pandemic Response When the pandemic wave is over, LTCHs should meet with local public health unit staff and other community partners to review the response to the pandemic in the home and in the community, identify what was handled well and what could be improved, and prepare for a possible next wave.
19.14 Next Steps The MOHLTC and the long-term care sector will continue to address outstanding issues, including:
• developing provincial criteria to help communities determine which patients will be admitted to hospital, cared for in a LTCH, and served by home care during an influenza
• maintain up-to-date contact lists for staff and residents’ families/next of kin or caregivers
• use influenza fact sheets and other
• developing policies and agreements to ensure that residents who are discharged home or to the care of family members will not lose their LTCH bed and that any discharging of residents related to the pandemic will not have a negative effect on LTCHs’ operating budgets.
materials provided by the local public health unit or the MOHLTC, including Important Health Notices, so messages to the public are consistent
• have an alternate or backup system of communication
• post signs at all entrances indicating the situation (e.g., pandemic activity in the community and/or pandemic activity within the home), advising visitors of the potential risk of either introducing influenza into the home or acquiring influenza within the home, and of any visiting restrictions, if applicable
References 1.
Ontario Ministry of Health. Influenza Prevention and Surveillance Protocol for Ontario Long-Term Care Facilities. November 1999.
2.
Ontario Ministry of Health and LongTerm Care. A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes at:
Chapter #19: Long Term Care
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http://www.health.gov.on.ca/english/ providers/pub/pubhealth/ ltc_respoutbreak/ltc_respoutbreak.html. 3.
National Advisory Committee on Immunization (NACI). Statement on influenza vaccination for the 2007-2008 season. An advisory committee statement.
Chapter #19: Long Term Care
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19A. Long Term Care Home Tools
Contents Long-Term Care Home Pandemic Preparedness Checklist................................................................. 1
Ontario Health Plan for an Influenza Pandemic August 2008
Long-Term Care Home Pandemic Preparedness Checklist Task/Activity
Yes/No
Action Required
1. Planning 1.1 Has the LTCH designated a person responsible for pandemic planning and established a multidisciplinary pandemic planning committee (e.g., administration, medicine/nursing, infection control, occupational health, staff training, engineering, housekeeping, dietary, pharmacy)? 1.2 Does the LTCH have a pandemic influenza plan or a section in its emergency or respiratory infection outbreak plan that deals with the potential impact of an influenza pandemic? 1.3 Does the LTCH review/update its plans annually? 1.4 Does the LTCH have a collaborative planning relationship with other health care organizations in the community (e.g., local public health unit, emergency medical services, CCAC, acute care hospitals) to plan for patient care during an influenza pandemic? 1.5 Has the LTCH worked with local pandemic planners to identify strategies to manage a surge in deaths (e.g., signatures on death certificates, moving bodies out of the home, morgue capacity)?
2. Chain of Command 2.1 Is there a chain of command for implementing the pandemic plan? (i.e., if an administrator is not available, who is next in command?) 2.2. Has the LTCH designated people responsible for infection control and occupational health safety who are known to staff and available 24/7? 2.3 Are all staff aware of their roles/responsibilities during a pandemic outbreak?
3. Occupational Health and Safety/Infection Prevention and Control 3.1 Was the Joint Health and Safety committee/representative consulted when developing the pandemic plan? 3.2 Does the LTCH routinely provide training on the proper donning and removal of personal protective equipment? 3.3 Does the LTCH have plans to restrict access in affected areas of the home?
4. Communications 4.1 Has the LTCH established a communication system with the local public health unit and other partners? 4.2 Does the LTCH have a plan for communicating with staff, residents, volunteers and family members during a pandemic, including the person/s responsible for notifying staff and families? 4.3 Is there a designated area in the facility/website where staff can obtain information on/be alerted to a potential influenza pandemic? 4.4 Does the LTCH have a mechanism to communicate with outside services (e.g., physiotherapy, community nursing support, occupational therapy, dental services) in the event of a pandemic outbreak? 4.5 Does the LTCH have alternative methods of internal and external communication if the main method of communication is not available?
Chapter #19A: Long-Term Care Home Tools
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4.6 Has the LTCH designated a media spokesperson (and backup) and developed procedures for handling media requests? How will this person coordinate messages with the local public health unit? Are procedures consistent with the Public Health Information and Privacy Act (PHIPA)? 4.7 Has the LTCH made arrangements for signs to direct authorized personnel and visitors to proper entrances and screening procedures?
5. Human Resources 5.1 Has the LTCH identified the skills that will be required to treat infected and non-infected residents during a pandemic? 5.2 Has the LTCH identified the skills that existing staff, including administrative and non-patient care staff, can provide? 5.3 Does the LTCH have a staffing contingency plan in case 20 to 25% of staff fall ill during the peak period of a pandemic wave? 5.4 Does the LTCH have a staffing contingency plan in case no registered staff are available? 5.5 Does the LTCH have a policy for addressing work refusal? 5.6 Has the LTCH identified potential outside sources of human resources (e.g., nursing agencies, other community organizations, volunteers, family members)? 5.7 Has the LTCH discussed the potential for modified or changed roles during a pandemic with staff and collective bargaining units? 5.8 Have provisions been made (e.g., space, equipment, training, communications) for extra people who may come to the LTCH to provide services (e.g., volunteers and outside agencies)? 5.9 Has the LTCH developed, in collaboration with the Joint Health and Safety Committee or a health and safety representative, education and training programs for staff? 5.10 Has the LTCH developed plans to support staff during a pandemic (e.g., child care, transportation, psychosocial support, meals, accommodation, assistance with pet care)?
6. Education and Training 6.1 Does the pandemic plan specify who is responsible for developing and implementing the training program? 6.2 Does the plan include methods for ramp up and quick training for new and altered roles (e.g., have policies and procedures been made, have job action sheets been developed, have lesson plans been developed)? 6.3 Does the LTCH have ongoing, mandatory pandemic training programs (e.g., at orientation, annually) as well as just-in-time training programs?
7. Resident Care 7.1 Has the LTCH identified residents who could be cared for in other settings if necessary? 7.2 Has the LTCH identified services that must be maintained or enhanced during a pandemic? 7.3 Has the LTCH identified services that could be reduced or deferred during a pandemic? 7.4 Has the LTCH home identified residents who are at high risk for negative outcomes (e.g., risk for choking and should not be fed by clerical or housekeeping staff or by volunteers)?
Chapter #19A: Long-Term Care Home Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
8. Antivirals and Vaccine 8.1 Does the LTCH have adequate capacity to store antivirals and vaccines (including cold chain for vaccines)? 8.2 Does the LTCH have medical directives and signed informed consents in place to allow for the rapid prescribing and administration of antivirals and vaccine? 8.3 Does the LTCH have the capacity to track the distribution of antivirals and vaccine, and report adverse events?
9. Surveillance 9.1 Have steps been taken to minimize and control points of access in the building and areas (e.g., where antivirals and vaccine are stored)? 9.2 Does the LTCH have a plan to initiate active screening of staff and visitors for FRI/ILI? 9.3 Does the LTCH have systems in place to detect an outbreak? 9.4 Is the LTCH aware of the information it will be required to report, and how that information will be reported to public health (i.e., through the web portal)?
10. Support for Visitors, Families and Volunteers 10.1 Does the plan include a mechanism to deal with anticipated increases in visitors seeking to gain entrance to or remove residents from the LTCH? 10.2 Has the LTCH made provisions to handle family needs related to the anxiety and shock of an influenza pandemic? 10.3 Have personnel been designated to control and take care of issues that arise due to visitors?
11. Supplies 11.1 Has the LTCH identified the supplies required for patient care and infection prevention and control during an influenza pandemic and developed a one-month stockpile (see Chapter 10A for equipment and supplies template)? 11.2 Will the LTCH’s suppliers be able to fulfill contracts during an influenza pandemic? If not, has the LTCH identified a backup source of supply? 11.3 Does the LTCH have access to an adequate supply of commonly used pharmaceuticals (e.g., ciprofloxacin, doxycycline, bronchodilators)? 11.4 Has the LTCH identified and established relationships with other health care facilities to coordinate stockpiling? 11.5 Has the LTCH made arrangements to obtain supplies for life sustaining treatments (e.g., peritoneal dialysis)?
Chapter #19A: Long-Term Care Home Tools
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Ontario Health Plan for an Influenza Pandemic August 2008
20. Guidelines for First Nations Communities With the exception of a few small outposts that isolated themselves, there was by early 1919 only one place the virus had missed. The Great Influenza, John M. Barry
There are 134 First Nations communities in Ontario. Of those, 106 are non-isolated (i.e., road access < 90 km to physician services) and 28 are isolated (i.e., regular flights, no year-round road access, good telephone and radio services). Of the 160,000 First Nations people in Ontario, about 80,000 live in First Nations communities. The Province of Ontario, the Government of Canada through First Nations and Inuit Health (FNIH) and the First Nations communities share responsibility for First Nations health services in Ontario: •
FNIH’s primary mandate is for First Nations people living in First Nations communities. FNIH provides primary care services (including emergency services) and public health services in remote and isolated areas where there are no provincial services readily available (see map next page).
•
First Nations people living outside First Nations communities will have their health needs met, like other Ontarians, by the provincial health care system.
•
The relationship between local public health units and First Nations communities varies across Ontario. Some health units have no contact with First Nations communities while others deliver services such as immunization clinics.
FNIH, the provincial government and public health units have been collaborating informally to meet the health needs of First Nations Chapter #20: Guidelines for First Nations
communities; however, they have not clearly defined their roles during a public health emergency. The Ministry of Health and Long-Term Care (MOHLTC) is working with First Nations and Inuit Health (FNIH) of Health Canada and the Chiefs of Ontario (COO) to develop plans to meet the needs of First Nations communities during an influenza pandemic. This chapter sets out the steps that MOHLTC, FNIH and COO will take to provide First Nations people living in First Nations communities in Ontario with the same access to influenza pandemic-related services, resources and stockpiles as other residents of the province.
20.1 Objectives •
To identify the needs of First Nations communities during an influenza pandemic.
•
To identify the roles and responsibilities of the Ontario Ministry of Health and Long-Term Care, First Nations and Inuit Health (FNIH), and First Nations communities in responding to an influenza pandemic.
In the event of an influenza pandemic, the goal is to provide First Nations people living in Ontario with the same access to pandemic-related resources and stockpiles as other residents of the province. For First Nations people living in the 134 First Nations communities in Ontario, the situation will be more complex. Health services in these communities are currently provided by nurses, community 20-1
Ontario Health Plan for an Influenza Pandemic August 2008
health representatives, visiting physicians and nurse practitioners employed by FNIH or the Bands or MOHLTC. In
remote areas, people who need hospital care are flown to larger centres where they receive services funded by the MOHLTC.
Figure 20.1: Map of FNIH Health Services
(e.g., telephone, video consultations) to access information and care
20.2 Planning Assumptions Because of the rural, remote or isolated nature of First Nations communities: •
services – such as physician visits and transportation (air ambulance) – will be disrupted during an influenza pandemic, and alternative arrangements will be required
•
communities will have to make effective use of available technology
Chapter #20: Guidelines for First Nations
•
timely distribution of antivirals, vaccine and supplies may be an issue.
First Nations people living outside First Nations communities will have equitable access to the influenza programs and services in their communities, including education and information, antivirals, vaccine when it becomes available, and assessment and treatment services.
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Ontario Health Plan for an Influenza Pandemic August 2008
Compared with the general Canadian population, First Nations people have four times the rate of hospital admissions for pneumonia. This reinforces the importance of equitable access to prevention, assessment and treatment services for First Nations people in Ontario.
where there are First Nations communities. If there is an influenza outbreak in a certain geographic area, FNIH notifies all adjacent communities. •
As part of preparedness planning, FNIH will continue to monitor influenza cases and provide reports to the MOHLTC. FNIH will provide reports with the same frequency as required from the province’s public health units.
•
The MOHLTC will work with FNIH to provide necessary information about the incidence and prevalence of influenza in neighbouring areas. FNIH will share these data with the First Nations communities in a timely manner.
20.3 Surveillance FNIH has developed a surveillance system for influenza-like illness (ILI) in First Nations communities. Sentinel health centres, schools and daycares report cases of influenza or absences due to influenza (see Figure 20.2). FNIH uses this information to monitor influenza activity in all geographic areas
Figure 20.2: ILI Surveillance Sites and Absences Monitoring Sites 2006
Chapter #20: Guidelines for First Nations
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Ontario Health Plan for an Influenza Pandemic August 2008
20.4 Health Human Resources FNIH is working with the First Nations communities to develop a pandemic health human resources (HHR) plan, and identify nurses and other health professionals who will provide care in the communities during an influenza pandemic. Once the plan is developed, it will be included in this chapter. Training MOHLTC and FNIH will collaborate to develop training materials for staff working in First Nations communities, and continue to look for opportunities to share resources, knowledge and experience: •
•
The MOHLTC is currently developing generic training modules for health care workers across all sectors. FNIH and a First Nations nurse will join the working group, and the modules will be made available to nursing stations, health centres and long term care facilities in First Nations communities. They will also be posted on the web whenever possible. The MOHLTC’s mandate does not include training; however, individual municipalities may be offering training. Health care workers employed in First Nations communities will be given the opportunity to participate in any hands-on training offered by their local public health unit/municipality, and FNIH and MOHLTC will identify programs available to assist with the cost (e.g., the Nursing Initiative managed by the RNAO, which is part of the province’s nursing strategy).
Chapter #20: Guidelines for First Nations
•
FNIH has developed clinical guidelines for First Nations nurses, and has shared these with the province.
•
The MOHLTC will develop a decision tree for use by Telehealth Ontario staff to ensure that, during a pandemic, individuals are directed to the appropriate setting/services. This decision tree will be shared with FNIH, COO and the Political Territorial Organizations (PTOs) for use in establishing telehealth services.
20.5 Antivirals and Vaccine First Nations people in Ontario are concerned about access to antivirals and vaccine during a pandemic, and want to be sure they have equitable access to government stockpiles. Antivirals Ontario is committed to building a large enough stockpile of antivirals by 2008 to treat 25% of the population (i.e., the proportion likely to be sick enough to require treatment) and to provide equitable access to antivirals for anyone in the province who is sick, including First Nations people. The Public Health Agency of Canada is currently developing a national policy on access to antivirals for prophylaxis, which will address the needs of health care workers and other critical infrastructure workers. When that is complete, Ontario will develop a provincial policy, which will apply to all residents of the province, including First Nations people.
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Ontario Health Plan for an Influenza Pandemic August 2008
In the event of a pandemic: •
•
•
•
First Nations people living outside First Nations communities who become ill will access antivirals in the same way as other people in the province: through Flu Centres and hospitals. The MOHLTC will inform the organizations responsible for distributing/administering antivirals about their legal obligation to provide antivirals to all citizens, including First Nations people. Any communication with health organizations about serving First Nations people will be shared with FNIH, COO and the Political Territorial Organizations (PTOs). First Nations people living in First Nations communities who become ill will access antivirals through their health centres and nursing stations. Ontario will provide antivirals to FNIH, which will be responsible for distributing them to First Nations communities. For security reasons, the province will not distribute antivirals until directed to do so by the Chief Medical Officer of Health for Ontario. FNIH will be responsible for working with First Nations communities to develop a secure way to transport, store and distribute antivirals in accordance with provincial policy. The First Nations communities will be responsible for maintaining a secure storage and distribution system for antivirals, for tracking their use, and for monitoring and reporting any adverse reactions. Because it may be difficult to distribute antivirals quickly to some isolated First Nations communities (i.e., within the 48 hours required for
Chapter #20: Guidelines for First Nations
treatment to be effective), MOHLTC will provide FNIH with a small standing stockpile of antivirals that can be distributed immediately to the appropriate communities. FNIH will be responsible for providing appropriate storage and security for this small stockpile. Vaccine It will take four to five months after the pandemic strain is identified to develop a vaccine. Ontario is committed to providing equitable access to influenza vaccine – once it is developed – to all residents of the province. The federal government has negotiated an agreement with a manufacturer to deliver enough vaccine to give one dose to the entire population within four months of a vaccine being developed. Vaccine requires a cold chain storage system. At the current time, First Nations communities receive their vaccine supplies either directly from their local public health unit (i.e., communities in the South and Thunder Bay Zones) or from a nearby hospital, which receives its supplies either from a local health unit or the government pharmacy (i.e., Sioux Lookout). Depending on the distance, vaccine is either transported in vaccine bags with ice packs or in hard coolers with ice packs and temperature indicators. In the First Nations communities, vaccine is stored in refrigerators located in the health centres or nursing stations, and refrigerator temperatures are monitored daily and recorded in a log book. During an influenza pandemic, the same supply and distribution chains and procedures will be used because they provide the necessary cold storage system as well as the experience to distribute and
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manage a vaccine program.
located in Quebec.
When a vaccine becomes available:
The goal of pandemic planning is to ensure that the Mohawks of Akwesasne have equitable, timely access to antivirals and vaccine during a pandemic. To be able to receive pandemic health services effectively and efficiently, the Mohawks of Akwesasne have requested that Ontario be responsible for distributing antivirals and vaccine for the entire community. Representatives of the MOHLTC, FNIH, the Quebec Ministry of Health and the Mohawk Government will meet to discuss this request and determine the most effective way to supply and distribute antivirals and vaccine for this community.
•
First Nations people living outside First Nations communities will access vaccine through the same sites as other people in the province (e.g., public health units, community immunization clinics). The MOHLTC will work with local public health units to educate public health staff about their legal obligation to provide vaccine to all citizens, including First Nations people. Any communication with public health units about serving First Nations people will be shared with FNIH, COO and the PTOs.
•
Local public health units/hospitals will be responsible for distributing vaccine in a timely way to First Nations communities. The supplies that health units/hospitals receive will take into account the needs of First Nations communities.
•
Staff at the First Nations health centres will be responsible for maintaining cold storage, administering vaccine in their communities, and maintaining immunization records, including reporting any adverse event, according to FNIH’s current vaccine distribution policies and procedures (see Immunization Protocol, First Nations and Inuit Health Branch Ontario Region, Health Canada, Chapter 4).
Antivirals and Vaccines for the Mohawks of Akwesasne The Mohawks of Akwesasne are in a unique situation because their community covers an area that includes part of Ontario, Quebec and upper New York State. The community’s health centre is Chapter #20: Guidelines for First Nations
For more information on antivirals and vaccine, see Chapter #9.
20.6 Supplies and Equipment Stockpiles First Nations health centres will follow the same policies and procedures as other organizations in Ontario for stockpiling supplies of personal protective and other medical equipment, which is: •
FNIH is responsible for ensuring the health centres in First Nations communities have and maintain an initial four-week stockpile of N95 respirators, eye protection, gowns, gloves and other equipment.
•
the Ministry of Health and Long-Term Care is responsible for maintaining an additional four-week stockpile of N95 repirators, eye protection, gowns, gloves and other equipment that will be available to First Nations communities. This will provide an adequate supply for the first wave (i.e., six to eight weeks) of the pandemic, in case of any disruption in traditional supply chains.
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MOHLTC and FNIH will work together to develop a plan for distributing supplies to First Nations communities during a pandemic. Note: OHPIP covers supplies stockpiling for the health system only; it does not include supplies that may be required for workers providing critical infrastructure services (e.g., power, transportation). This will be the responsibility of other provincial ministries and federal departments.
•
FNIH is working with First Nations communities to identify sites for Flu Centres, such as schools and community centres. The communities are looking at ways to work together to establish shared sites that will make the best use of limited resources.
•
Ontario has not yet identified the funding source for equipment/ infrastructure for the Flu Centres. The MOHLTC and FNIH will meet with Indian and Northern Affairs Canada (INAC) to resolve supply/ infrastructure issues.
20.7 Influenza Centres/Alternate Care Sites Ontario communities are planning to establish Influenza Centres/alternate care sites that will provide primary assessment and treatment services for people with influenza symptoms, and reduce the pressure on primary care physicians and hospitals. •
•
First Nations people living outside First Nations communities will have the same access to Flu Centres as other residents of their communities. The MOHLTC will establish guidelines for Flu Centre policies and procedures, which will require organizations to make it explicit that First Nations people have the same right to services as other citizens of Ontario. Training programs for Flu Centre staff will address issues of access to service for First Nations people, stigma and discrimination. The guidelines for Flu Centre policies and procedures will be shared with FNIH, COO and the PTOs. Statements from the Chief Medical Officer of Health for Ontario about where people are to go for care issued during a pandemic will also be shared with FNIH, COO and the PTOs.
Chapter #20: Guidelines for First Nations
20.8 Communications First Nations communities in Ontario will have the same access to information as other communities in the province, and be part of the MOHLTC information cycle, pictured in Figure 4. (For more detailed information about communications and the information cycle, see Chapter 12.) •
FNIH will be included on the distribution list for Important Health Notices issued by the MOHLTC at 0000 h. FNIH will distribute relevant information to the COO and PTOs which, in turn, will disseminate information to the communities. Important Health Notices will also be available on the MOHLTC web site.
•
FNIH, COO and the PTOs will participate in the 0830 h videoconference/teleconference with the MOHLTC and all health stakeholders.
•
At 1300 h, FNIH will participate in the Public Health teleconference with the province.
•
FNIH will hold a teleconference with COO and PTOs at 1500 h. FNIH and PTOs will collectively document any 20-7
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concerns, issues and recommendations identified by First Nations communities on a predetermined form. FNIH will forward the form to MOHLTC. In
addition, FNIH will be assigned a contact person in the Ministry of Health and Long-Term Care Emergency Operations Centre.
Figure 20.3: First Nations Participation in Pandemic Information Cycle
20.9 Transportation First Nations communities are highly dependent on land and air ambulances to transport ill patients from remote communities to hospitals in larger centres. At the current time, 60% of aid evacuations in Ontario are people coming from remote northern communities. Both air and land ambulance services are likely to be disrupted during a pandemic. First Nations communities are also highly dependent on air services to transport supplies into communities. To meet First Nations communities’ need for transportation services during a pandemic: Chapter #20: Guidelines for First Nations
•
FNIH will pay for the cost of taxis or other transportation services within the First Nations communities.
•
MOHLTC is now working with the province’s Emergency Services, including ambulance services, to develop a plan to maintain critical services during a pandemic. This plan will include steps to be taken to meet the needs of First Nations communities.
•
FNIH will negotiate contracts with independent local airlines and pilots to transport supplies and personnel during a pandemic.
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21. Psychosocial Support: Outline Fear began to break down the community of the city. Trust broke down. Signs began to surface of not just edginess but anger, not just finger pointing or protecting one's own interest but active selfishness in the face of general calamity ... The Great Influenza, John M. Barry
During an influenza pandemic, both health care workers and patients/members of the public may experience stress that they cannot manage with their everyday coping skills and resources. Long working hours, disruption in their lives, anxiety and fear over becoming ill, or having a family member who is ill can lead to emotional, behavioural and social problems, and affect people’s ability to function. It is normal for people to experience confusion, sadness, irritability, sleep and appetite disturbances and other signs of stress. In some cases, the psychosocial footprint of an influenza pandemic may be larger than the medical consequences.
at greatest risk of serious psychosocial problems include those who have a previous history of traumatic events, lose a family member of friend, witness a lot of death, face extreme demands during the pandemic, have to make difficult triage decisions during the pandemic, feel personally at risk, or have pre-existing social or psychological problems.
Psychosocial support during a pandemic is often more practical and psychological. It is about ensuring that people have practical support, such as information, child care, transportation, pet care, and help managing home responsibilities in the midst of heavy work demands.
•
To support health care organizations in planning for the psychosocial needs of their staff.
•
To minimize the psychosocial impacts of an influenza pandemic on health care workers, patients and the public.
People’s emotional reactions to a pandemic may last days or weeks, but those reactions will usually resolve as people come to understand what has happened and as the pandemic wave subsides.
Principles of Psychosocial Support During a Pandemic
Most people will recover from the psychological effect of a pandemic on their own, but supportive programs and services can help them regain a sense of stability and well-being. A small number of people may experience more serious psychological difficulties and require mental health interventions. People
Chapter #21: Psychosocial Support
This chapter is a guide for local planners in implementing psychological support programs for health workers and the public/patients they serve. It is NOT a selfhelp guide for individuals.
Objectives
•
Do no harm (Psychological First Aid)
•
Ensure safety and basic needs
•
Focus on resiliency
•
Provide timely and accurate information
•
Normalize daily life
•
Build community capacity and resiliency
•
Ensure cultural competence
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Psychosocial Services for Health Care Workers •
Communication/Education
•
Effective Management Structure
•
Workplace Wellness Programs
•
Training
•
Practical Support
•
Counselling
Psychosocial Services for Patients and Public •
The Risk of Mass Panic and How to Manage It
•
Reducing the Potential for Discrimination
•
Communication/Education
•
When to Seek Assistance and Links to Services
•
Protocols to help health care providers identify people who are presenting because of fear rather than illness
•
Training
Psychosocial Planning Activities Psychosocial planning activities by pandemic planning phase are currently being developed.
Next Steps •
Work with mental health providers/organizations to develop the full chapter
•
Develop web links and references for outreach services, local services, practical supports for vulnerable people (e.g., economically disadvantaged, socially marginalized, psychiatric problems, frail elderly, single parents with young children, people with language/communication needs).
Chapter #21: Psychosocial Support
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22. Natural Death Surge Planning Strategy The city morgue had room for thirty-six bodies. Two hundred were there. Bodies lay in homes where they died ... Families closed off rooms where a body lay. The Great Influenza, John M. Barry
This chapter is excerpted from the Ministry of Community Safety and Correctional Services Influenza Pandemic Plan (2008). The intent of the Natural Death Surge Planning Strategy is to provide information that may assist influenza pandemic planning. The implementation of the strategies and tools are NOT mandated or directed for use in local influenza pandemic planning, and this does NOT replace existing influenza pandemic plans, procedures or guidelines.
Preamble An increase in mortality is expected during an influenza pandemic, but accurate predictions of mortality cannot be made before the pandemic virus emerges. The World Health Organization advises that death rates are largely determined by four factors:
• the number of people who become infected;
• the virulence of the virus; • the underlying characteristics and vulnerability of affected populations; and
• the effectiveness of preventive measures. All estimates for anticipated number of deaths are purely speculative. The World Health Organization has estimated from 2 million to 7.4 million deaths worldwide1 and, based on a 35% attack rate, Ontario public health officials estimate a minimum
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http://www.who.int/csr/disease/ influenza/pandemic10things/en/ Chapter #22: Natural Death Surge Planning Strategy
of 6,864 to a maximum of 20,072 deaths in Ontario over the course of the influenza pandemic. For planning purposes, Ontario estimates that the most likely number of fatal cases is 12,303.2 Of those fatalities, 70% (8,612) will be in the hospital setting. Preparedness planning is essential for all levels of government to ensure that systems and procedures are in place to manage a surge in natural deaths including the proper screening, recognition, reporting of, and disposition of human remains. A SARS Commission recommends a pre-planned response involving the funeral industry, the Ministry of Health and Long-Term Care, public health, the hospital community, Emergency Management Ontario, and the Office of the Chief Coroner, supported by agreed upon policies, procedures, protocols, memoranda of understanding, and tabletop drill exercises to prevent the problems that arose during the Severe Acute Respiratory Syndrome outbreak. 3
Natural Death Surge vs. Multiple Fatality An important concept for planning is the fact that an influenza pandemic would likely result in a “Natural Death Surge” rather than a “Multiple Fatality Event” and therefore would not likely lead to an
2
Ontario Health Plan for an Influenza Pandemic, 2007, “Table 3.1: Estimated Impact on an Influenza Pandemic by Attack Rate” 3 The SARS Commission, Executive Summary, Spring of Fear, pg. 58
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activation of the Provincial Multiple Fatality Plan, which is maintained by the Office of the Chief Coroner. A coroner’s investigation would likely be required for a death resulting from a Multiple Fatality Event, but not necessarily from a Natural Death Surge.
early stages of an influenza pandemic, involvement of the Office of the Chief Coroner may be quite significant, as there may be important public safety issues to consider. As the pandemic evolves, involvement of the Office of the Chief Coroner will likely diminish considerably.
A Multiple Fatality Event can be defined as an:
The Coroners Act, RSO, 1990, Ch C.374 provides the legal framework under which coroners in the province conduct investigations into many deaths. Without appropriate jurisdiction, the coroner may not investigate a death. The circumstances where a coroner does have jurisdiction are outlined in Section 10 of the Coroners Act and include all nonnatural deaths, as well as many natural deaths. The “normal” business of the coroner will continue during an influenza pandemic.
“Incident or event (usually a single event) where several persons die, and where the number of deaths exceeds the capabilities of the local resources (personnel, equipment, facilities) to respond with appropriate investigation, recovery of remains, examination of the bodies, identification of the decedents, reporting of findings, and ultimate disposition of the human remains (repatriation, burial, cremation).” Natural Death Surge can be defined as: “An increased number of deaths from natural causes that can occur over a period of time (weeks to months) rather than in one incident or event. The impact of an ongoing natural death surge may impact local systems and capabilities.”
Role of the Office of the Chief Coroner during an Influenza Pandemic The Office of the Chief Coroner, through the Ministry of Community Safety and Correctional Services, will be actively involved provincially and regionally, along with other stakeholders, in providing input into the prevention, mitigation, preparedness, response and recovery to an influenza pandemic. Coroners must have the appropriate jurisdiction to investigate deaths, and the involvement of the Office of the Chief Coroner in dealing with a pandemic will depend entirely on circumstances. In the
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All non-natural deaths, including homicides, suicides, accidents, deaths in custody, and those of undetermined circumstance will require investigation, as will other deaths that fall under Section 10 of the Coroners Act. Included in the natural deaths are those that are sudden and unexpected. Deaths resulting from a declared influenza pandemic would be regarded as natural, but not necessarily sudden and unexpected; therefore, the coroner would not automatically have jurisdiction or have the requirement to become involved in any investigation. Coroners may not be as readily available during a declared pandemic because they will likely be heavily involved in caring for patients within their own areas of medical practice. Should they contract influenza themselves, they may be 4
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medically unfit or prohibited from working.
Influenza Pandemic Screening Questionnaire
It is anticipated that in the event of an influenza pandemic, communities may assume that they will be able to request coroners to respond to a death that would not ordinarily require a coroner’s investigation. This may be for no other reason than to perform certain requisite tasks and complete documentation when there is no one else available to assume responsibility. The Office of the Chief Coroner has emphasized that this type of request must be reserved for exceptional circumstances, and cautions that it cannot guarantee that coroners will be available to respond.
Local planners assigned to develop a pandemic plan for their organizations are faced with the perplexing challenge of managing potentially high numbers of deaths in a declared influenza pandemic. The Office of the Chief Coroner has developed and shared with local planners a questionnaire to assist local communities in dealing with the anticipated surge in natural deaths during an influenza pandemic.
The Office of the Chief Coroner will provide guidance and advice to communities on areas where it has expertise, or experience, to assist with local planning efforts to ensure that appropriate local strategies are in place for dealing with the expected surge in natural deaths. Local natural death surge strategies should be a component of local pandemic plans for implementation once a pandemic is declared. These strategies should be discussed with the Regional Supervising Coroner, local funeral service providers, cemeteries and crematoria, who will have key roles in the efficient shortterm storage, handing, and ultimate disposition of remains. The Funeral Service Association of Canada and the Ontario Board of Funeral Services have published a Guide to Pandemic Planning5 for their licensees and staff.
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Use of this questionnaire will apply primarily to deaths occurring in the community, rather than in a designated health care facility, and will be of value in circumstances where there may be a reasonable presumption that the death was due to influenza. It is assumed that health care facilities will have mechanisms and personnel in place to pronounce and certify deaths that occur within their premises, consistent with their current responsibilities. The Office of the Chief Coroner has not mandated the use of the questionnaire, but the questionnaire can assist in distinguishing those deaths that must be referred to the coroner from those that can be assumed to be due to an influenza pandemic. It is provided as a guideline and can be amended to meet local needs to include such things as local procedures for the reporting of – and documenting requirements for – influenza pandemic deaths. The use of an Influenza Pandemic Screening Questionnaire will require that local public health and response agencies work together to provide for the appropriate training in its use and application, as those who have been determined by the community to utilize
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the screening questionnaire will find it different from normal protocols and procedures. The Ministry of Community Safety and Correctional Services and the Ministry of Health and Long-Term Care are jointly developing a training module to accompany the Screening Questionnaire. The training module, when available, will be distributed and should be customized for local use. Training should be implemented by the agencies who will use the questionnaire, and the Regional Supervising Coroners will be available in an advisory capacity to assist in developing the training, if required. The questionnaire is broken into 3 sections:
• Section one determines the necessity to involve the coroner in circumstances that would fall under Section 10 of the Coroners Act.
• Section two elicits a medical history, including signs and symptoms, possible history of exposure, and vulnerability to succumbing to influenza infection. Its purpose is to allow the screener to come to a presumptive diagnosis that the person probably died from influenza in circumstances where an influenza pandemic has been declared.
• Section three provides for the documentation of date and time of pronouncement of the death. It also notes relevant contact information for the coroner (if contacted); the funeral home responsible for body removal from the scene; and the person responsible for completion of the form. The concept of an “Influenza Pandemic Response Team” has evolved in local pandemic planning from the need to conserve utilization of other valuable first Chapter #22: Natural Death Surge Planning Strategy
responder resources. Communities may want to consider identifying and training in advance a team that will be trained on the Influenza Pandemic Screening Questionnaire. If appropriate, the team would be dispatched to a suspected influenza pandemic death to confirm that death has occurred; to determine whether the coroner should be called or not; to ascertain whether the death was likely due to influenza and to initiate the process of having the body removed from the scene for ultimate disposition (funeral, burial, cremation). See Appendix 1 for the Influenza Pandemic Screening Questionnaire.
Management of a Surge in Natural Deaths With the anticipation of limited resources during an influenza pandemic, changes to the normal processing of human remains may be required, along with short-term adaptations to an organization’s day-today operating policies and procedures. Local planners, with participation from the Regional Supervising Coroner, local public health officials, funeral boards,6 and other appropriate local authorities, should examine each step in the management and processing of human remains to determine what issues may arise during an influenza pandemic. Strategies should be developed to address those issues and ensure the continuity of the death management process. This may include developing additional documentation to complement the initial screening questionnaire, described in the previous section, so that timely completion of required documentation can be accomplished. It may also include assigning and training appropriately
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qualified individuals, such as paramedics or community nurses, as pandemic death screeners. In addition, and to ensure that no potential criminal matters are overlooked in the process, discussions should involve the local police service, who may want to assign experienced death investigators. Local planners are reminded that there is currently no statutory legal requirement concerning who can pronounce death. There may, however, be a societal expectation that individuals formally pronouncing death in the community setting during a pandemic have some form of medical training, or alternatively, be in a position of authority (police officer). Under current legislation, physicians complete the majority of Medical Certificates of Death. Consideration is being given to modifying the regulations under the Vital Statistics Act7 to allow for a broader spectrum of health care professionals, including nurses and paramedics, to perform this function. Communities may wish to arrange for a voluntary roster of physicians, through their local hospital medical staff organization, to be available to expedite the signing of Medical Certificates of Death. Community planners, with the assistance of local funeral directors, must determine where the body of a deceased person can be taken (funeral home, central body storage facility or morgue) in anticipation of completion of a Medical Certificate of Death by a legally qualified individual.
investigating coroners, as a last resort, will attempt to facilitate or expedite any requisite paperwork, such as completion of Medical Certificates of Death and cremation applications, so as to allow for death registration and disposition of the remains as quickly as possible. This may require the faxing of documentation to the office of the Regional Supervising Coroner, and temporary acceptance of such documentation by Division Registrars and other government officials. Municipalities should also review their death registration procedures to ensure that they will be able to address increased requests in a timely fashion. Strategies to consider include increasing hours of operation for registrations, and appointing additional Deputy Division Registrars and Sub-Registrars, as permitted in the Vital Statistics Act, s.38.8
Natural Death Surge Planning Strategy Chart Table 22.1 outlines the steps in the death management process including the proper screening, recognition, reporting of and disposition of human remains at the local level. It is not prescriptive, but suggests issues that may require strategies be developed at the local level in consultation with the Regional Supervising Coroner, local public health, first responders, and community emergency management coordinators and planners.
Where no other qualified individual is available to do so, the Regional Supervising Coroner and/or local
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Table 22.1: Natural Death Surge Planning Strategy Chart Step 1 – Death in Community Setting (outside health care facility) A key concept of planning for a significant increase in the number of natural deaths in the community setting (i.e., outside of health care institutions) is the recognition by caregivers or acquaintances that death has occurred. Community planners may wish to consider obtaining information from the caregiver’s initial call to determine the appropriate response. It is important to consider that a tiered emergency response (EMS, Fire, Police) not be activated for every influenza pandemic death, if not required. These resources will be struggling to maintain other emergency service calls that require their expertise. Considerations can be given to setting up a designated phone number, other than the normal emergency number (911), that is answered by trained calltakers when screening calls from caregivers who may be reporting a suspected influenza pandemic death. The number would need to be publicized through local media and educational campaigns, and special training for the calltakers would be required. Alternatively, the existing emergency number system (911) may be utilized. With appropriate modifications to ambulance algorithms and training of the calltakers, a preliminary intake may distinguish if the patient has likely expired from the influenza pandemic, or from some other reason, to determine the appropriate response. Requirements
Factors to Consider
Planning Strategies
• Family/caregiver believes person has died • Calls influenza pandemic designated number or emergency number
• May not recognize that death has occurred • Unaware of public education issues • Burden to emergency response system (i.e., 911)
• Provide education regarding signs, symptoms of death through pamphlets, TV infomercials, website • Provide education on proper steps to take, designated number to call (avoid 911) • Set up designated phone number with trained personnel or utilize existing 911 operator system
Step 2 – Dispatch of Appropriate Resources The concept of an “Influenza Pandemic Response Team” (PRT) has evolved from the need to conserve utilization of other valuable first responder resources. Communities may want to consider identifying and training in advance PRT that will be dispatched to a suspected influenza pandemic death to confirm that death has occurred (Pronounce Death); to determine whether the coroner should be called or not; to ascertain whether the death was likely due to an influenza pandemic; and to initiate the process of having the body removed from the scene for ultimate disposition (funeral, burial, cremation). Discussions in several communities have determined that the most logical members of a PRT would include a police officer with death investigation experience and a medically trained individual (EMS or nurse). Community planners and the involved agencies would need to determine criteria for having PRT members on standby and when to actively deploy them. Decisions regarding equipment (PPE, basic resuscitation kit) and types of vehicles would be left to the individual community. Requirements
Factors to Consider
Planning Strategies
• Calltaker confident from information provided that victim is deceased • No need for full tiered response • Trained influenza pandemic responders on standby for deployment to scene
• Calltaker has appropriate training and algorithm to follow to verify that death has occurred • Trained “Pandemic Response Teams” (PRTs) of skilled individuals with sufficient experience, equipment and personal protection • Consider legal liability issues
• Develop appropriate algorithm and train calltakers in its application • Identify members of PRTs in advance – police with death investigation experience, EMS, RN • Monitoring mechanism to determine when to activate PRTs • Consider planning an on-call system, 24/7, specifically for this task
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Step 3 – Pronouncement of Death The Vital Statistics Act legislates who is qualified to certify death, but there is no specific requirement concerning who can pronounce death. It may be necessary during an influenza pandemic for communities to consider other alternatives for death pronouncement. Those with experience in witnessing death (EMS, nurses, police officers) could perform this task, if required. There may be a need to modify existing policies and protocols, as well as existing regulations, to allow for wider latitude of practice of such individuals in an emergency situation of a declared influenza pandemic. Requirements
Factors to Consider
Planning Strategies
• No statutory legal requirements in place • Medical training is desirable • Alternatively, a position of authority (police officer)
• If death occurs in the home then one of these authorized persons will need to be contacted • Availability of people able to do this task • Consider legal liability issues
• Provide public education on how to access an authorized person • Modify existing policies and procedures, or protocols to allow this (i.e., work outside normal parameters of Ambulance Act, police procedures)
Step 4 – Screening Questionnaire – Possible Death from Influenza A questionnaire has been developed by the Ontario Office of the Chief Coroner to assist PRT members with determining whether the death requires a coroner’s investigation. If it does not, further questions are designed to elicit whether a reasonable presumption can be made that the death was due to an influenza pandemic. If this is the case, the forms are completed and suitable arrangements are then made for the body to be removed from the site to a designated location (funeral home or temporary morgue). Reporting of these deaths must also be made to the Medical Officer of Health.
Requirements
Factors to Consider
Planning Strategies
• Screening questionnaire • PRT members trained in its use and interpretation • Community strategy for transportation of bodies
• Number of PRTs available to respond to death scenes • Training and familiarization with process of screening • Body removal services educated in process and willing to remove body to designated site (funeral home or morgue) without a Death Certificate
• Questionnaire made available to all communities for their consideration • Develop and outfit PRTs within communities in consultation with involved stakeholders (EMS, police, etc.) • Involve funeral service sector, body removal services in planning
Step 5 – Certificate of Death Under current legislation, physicians complete the majority of Medical Certificates of Death. Consideration is being given to modifying the regulations under the Vital Statistics Act to allow for a broader spectrum of health care professions to perform this function. Communities may wish to arrange for a voluntary roster of physicians, through their local hospital medical staff organization, to be available to expedite the signing of death certificates. Community planners would also need to determine whether bodies would be transported to local funeral homes or to a central body storage facility (morgue), with the understanding that death certificates would be completed at one of those locations. Appropriate documentation should accompany the body to the designated site for review by the death certifier. Requirements
Factors to Consider
Planning Strategies
• Person legally authorized to perform this task
• Not necessarily the same person who pronounced death • Availability of volunteers, designated persons legally qualified • Define location where certificate to be signed • Provide appropriate documentation to satisfy certifier
• Volunteer/rotating schedule of physicians willing to be available • Changes to existing legislation, regulations to allow broader range of certifiers within health professionals sector (RNs, EMS) • Corpse, all documentation located at funeral home for review • Consider collecting corpses and having one authorized person perform this task en masse to improve efficiency
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Step 6 – Wrapping of Body for Transportation In consultation with the Chief MOH and local MOHs, it should be determined what steps, if any, are required prior to the transport of bodies from a death scene. Requirements
Factors to Consider
Planning Strategies
• Determine necessity with MOH • Plastic sheeting (shroud) may suffice • Person(s) trained to perform this task
• Body bags/plastic shrouds • Supply of human and physical (body bags) resources
• Consider developing a rotating six month inventory of body bags, given their shelf life • Consider training or expanding the role of current funeral home staff to include this task • Provide this service in the home in conjunction with pronouncement and transportation to morgue.
Step 7 – Transportation to the Morgue Bodies must be treated with respect and dignity. Depending on the number of deaths and the community decision for where bodies will be taken following death pronouncement, transportation may be handled entirely by professional removal services, or may also be done by family members. Education of the public may be required if the latter is anticipated with any significant frequency. Families devastated by influenza pandemic deaths may require intervention by Social Services to assist with funeral arrangements and even basic issues of food and shelter. In situations where the responsible adult caregivers have succumbed, the local Children’s Aid Society may need to become immediately involved. Similarly other agencies such as Animal Control may need to be alerted to circumstances that require their involvement. Requirements
Factors to Consider
Planning Strategies
• Suitably trained personnel, stretcher and vehicle suitable for this purpose • Transport by family, if done with respect and appropriate dignity
• Availability of human and physical resources (including vehicles)
• Consider keeping old stretchers in storage instead of discarding • Look for alternate suppliers of equipment that could be used as stretchers in an emergency (e.g., trolley manufacturers) • Consider transport vehicles capable of handling more than one corpse per trip • Provide public education or specific instructions re: where to take corpses, whether the family must transport; how to do so appropriately • Assistance of Social Services, CAS, Animal Control, for cases where family may lack resources to react
Step 8 – Registration of Death Local municipalities may have to examine their current staffing levels and hours of operation for death registration. Appointments by Order in Council of additional Assistant Deputy Registrars needs to be contemplated well in advance of a declared influenza pandemic. Contingency plans should be considered for extended hours of operation, or after-hours availability to expedite death registration. Requirements
Factors to Consider
Planning Strategies
• Deputy Registrar or Assistant DR at municipal offices
• Sufficient persons appointed and trained to fulfill task • Hours of operation to accommodate increased demand
• Municipalities to review current complement of registrar positions • Expand hours of service, or provide on-call availability outside regular hours
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Step 9 – Storage of the Body Assuming that local funeral homes may have very limited surge capacity for body storage, and that existing morgue facilities (hospitals, Coroner’s Office, removal services) will likely be overwhelmed during an influenza pandemic, alternate solutions for temporary body storage must be made. Community planners must be sensitive to the potential repercussions of the general public associating temporary body storage with certain locations (ice rinks) or specific companies (cold storage facilities, refrigerated trucking companies). Local communities should dialogue with their funeral service providers and hospitals in determining an appropriate temporary body storage facility and its location. Storage may be required after death is pronounced, while the funeral arrangements or disposition decisions are being made. Following the funeral, there may be backlogs at cemeteries and crematoria that necessitate further short-term storage of bodies. Requirements
Factors to Consider
Planning Strategies
• A suitable facility that can be maintained at +4 to +8º Celsius
• Capacity of existing facilities in hospitals, funeral homes, removal services likely to be overwhelmed • “Traditional” alternatives may not be realistic or palatable to community (e.g. hockey rinks, refrigerated trucks) • Availability of refrigerated containers/trucks, or storage facilities • Placement of temporary body storage facility (ie. close to hospital morgue or funeral home)
• Identify and plan for possible temporary morgue sites • A contract or Memorandum of Understanding with appropriate suppliers • Funeral sector to explore options for temporary increase in capacity (pooling of resources, refrigerated units on site, etc.) • By-law revisions as required
Step 10 – Autopsy Examinations Autopsies will most likely not be required to confirm an influenza pandemic death. The OCC may have some initial involvement with surveillance and diagnosis confirmation to assist Public Health in the early stages of an influenza pandemic. Requirements
Factors to Consider
Planning Strategies
• Most deaths due to influenza pandemic will not need autopsy • Public health surveillance/confirming diagnosis • Consent of family, if not a coroner’s autopsy
• Availability of human and physical resources • May be legally required in some circumstances (coroner’s cases)
• Ensure that physicians and families are aware that an autopsy is not required for confirmation of an influenza pandemic death
Step 11 – Cremation Community planners should consult with local crematoria to ascertain current volumes of cremations and surge capacity, along with any limitations that extended hours of operation might pose. Requirements
Factors to Consider
Planning Strategies
• Transportation to crematorium • Availability of crematoria • A cremation certificate signed by coroner
• Capacity of crematorium/speed of process • Availability of coroner to review and issue certificate • Public Health requirements • May be advised as desirable alternative to burial
• Identify alternate vehicles that could be used for mass transport • Examine the capacity and surge capacity of crematoria within the jurisdiction • Discuss and plan appropriate storage options, if the crematoria become backlogged • Discuss and plan expedited cremation certificate completion processes through Regional Supervising Coroner’s Office
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Step 12 – Embalming Funeral service sector should review their needs for supplies and trained embalmers in the event of an influenza pandemic where deaths from natural causes might surpass in 6-8 weeks the normal volume normally encountered in 6 months. Requirements
Factors to Consider
Planning Strategies
• Vehicle for transportation from morgue • Trained persons • Embalming equipment • Suitable location • May not be necessary for cremation
• Availability of human and physical resources • Capacity of facility and speed of process
• Consult with service providers regarding the availability of supplies and potential need to stockpile or develop a rotating 6 month inventory of essential equipment/ supplies • Discuss capacity and potential alternate sources of human resources to perform this task (e.g., retired workers or students in training programs) • Consider “recruiting” workers who would be willing to provide this service in an emergency
Step 13 – Funeral Service Normal funerary practices may be significantly altered by a surge in natural deaths. Supplies may be limited; visitations may, of necessity, be shortened dramatically or curtailed by the MOH to prevent the spread of disease. Requirements
Factors to Consider
Planning Strategies
• Knowledge of available resources (location, caskets) • Timing • Visitations, service • Infection control measures to reduce risk of disease transmission in large gatherings
• Availability of caskets • Availability of location for service and visitation • Limitations on public gatherings • Need to expedite or accelerate the process • Competing public expectations (for specific day, number of guests, etc.)
• Shorten lead time for casket manufacture/ delivery • Consult with the Funeral Services Association of Canada (FSAC) • Training, public education in infection control measures from Public Health • Alternative of a memorial service at some time after the cremation/burial
Step 14 – Temporary Storage After Funeral See: Step 9 – Storage of the Body Requirements
Factors to Consider
Planning Strategies
• Suitable facility at +4 to +8º C
• Embalmed bodies, or bodies in caskets may be more acceptably stored in some facilities (e.g., cold storage)
• Expand capacity by increasing temporary storage sites
Step 15 – Burial Contingencies need to be considered to cope with extremes of weather, reduced manpower, shortage of equipment, cultural and religious requirements, etc. Bodies may require short-term storage following funeral services. Requirements
Factors to Consider
Planning Strategies
• Grave digger, space at cemetery
• Availability of grave diggers and cemetery space • Extreme cold and heavy snow fall
• Identify sources of supplementary workers
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Appendix 1: Influenza Pandemic Screening Questionnaire The following questionnaire, developed by the Office of the Chief Coroner, is designed to help the appropriate health care professionals exclude cases that require a coroner’s investigation and/or to make a presumptive diagnosis of influenza as the medical cause of death during an influenza pandemic. As noted under “Purpose,” the questionnaire is intended primarily for deaths occurring in a community setting rather than in health care facilities. Although it is not prescriptive for communities to use, it offers a means to assist communities to deal with the anticipated surge in natural deaths, and to expedite removal of decedents’ remains to a suitable site for ultimate disposition. If not utilized, a comparable approach should be considered by local community planners. The use of an Influenza Pandemic Screening Questionnaire will require that local public health and response agencies work together to provide for the
Chapter #22: Natural Death Surge Planning Strategy
appropriate training in its use and application, as those who have been determined by the community to utilize the screening questionnaire will find it different from normal protocols and procedures. The Ministry of Community Safety and Correctional Services and the Ministry of Health and Long-Term Care are jointly developing a training module to accompany the Screening Questionnaire. The training module, when available, will be distributed and should be customized for local use. Training should be implemented by the agencies who will use the questionnaire, and the Regional Supervising Coroners will be available in an advisory capacity to assist in developing the training, if required. The Office of the Chief Coroner cannot guarantee that the services of a coroner will be available during a declared pandemic for deaths not requiring an investigation under the Coroners Act.
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Screening Questionnaire for Possible Death from Influenza Pandemic Outside of a Health Care Setting (Note: the screening referenced here is limited to identifying cause of death not the broader screening of live individuals.) Purpose This questionnaire has been designed to be utilized by appropriate health care professionals to exclude cases that require a coroner’s investigation and/or to make a presumptive diagnosis of Influenza as the medical cause of death. It will apply primarily to deaths occurring in the community, rather than in a designated health care facility. It is assumed that, as is currently the case, health care facilities will have mechanisms and personnel in place to pronounce and certify the deaths, and will also be familiar with referrals to the Coroner’s Office. This document is subject to revision and finalization at the time of a declared influenza pandemic so as to ensure relevancy to the specific attributes of the particular virus strain involved.
Date:____________________________
Time:___________________________
Name of Deceased Person:________________________________________ Location:_________________________________________________________
Person Interviewed:________________________________________________
Relationship to Deceased Person:_______________________________
Contact Information:
Address:__________________________________ Phone:___________________________________
Interviewed by: (name and designation):________________________________
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Screening Questionnaire - Section One: Preliminary Questions to determine NECESSITY TO INVOLVE CORONER:
Does the MANNER of death appear to be other than Natural Causes? (“Other” would include apparent Accident, Suicide, Homicide, or Suspicious Circumstances)
Y
N
By history from caregivers, is the death both Sudden and Unexpected? (Assessor is to use his/her impression, not the caregiver’s view that the death was both sudden and unexpected)
Y
N
Has anyone expressed concerns regarding medical care? (Including caregivers, other relatives, health care professionals, etc.)
Y
N
Is it impossible to establish firm identification of the deceased? (No responsible person in attendance, or decompositional changes prevent visual identification)
Y
N
A “YES” RESPONSE to any of the above questions requires IMMEDIATE NOTIFICATION OF A CORONER and preservation of the scene.
If ALL RESPONSES are “NO”, proceed to section two.
Note: If there are no relatives, friends or acquaintances readily available who appear willing to assist with funeral arrangements and disposition of the body (burial or cremation), please contact the office of the Regional Supervising Coroner for your area to seek direction. There is provision under the Anatomy Act for the coroner to request assistance of the municipality in disposition of unclaimed bodies.
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Screening Questionnaire - Section Two: By history, has the deceased exhibited any of the following signs/symptoms suggestive that the current Pandemic Influenza infection might have led to the death: Sudden respiratory illness prior to death?
Y
N
Sudden onset of high fever or chills at outset of that illness?
Y
N
General malaise, back or muscle aches/pains, or severe prostration?
Y
N
Headache?
Y
N
Sensitivity to light?
Y
N
New onset of cough, with or without bloody sputum?
Y
N
New onset of head cold, +/- sore throat in early stages?
Y
N
Progressive shortness of breath?
Y
N
Has anyone else in the household experienced similar symptoms?
Y
N
Has there been any known or probable exposure to others with a diagnosis of influenza outside of the household?
Y
N
If the deceased received recent medical care, did the physician make a diagnosis of influenza or confirm influenza through lab testing [note: laboratory testing unlikely in most active stages of influenza pandemic]
Y
N
asthma, chronic bronchitis, emphysema
Y
N
valvular heart disease (known heart murmur), ischemic heart disease, or congestive heart failure?
Y
N
Has the deceased had a prior history of any of the following medical conditions that would make him/her more susceptible to death from influenza:
A “Yes” response to a majority of these questions can lead to a presumptive diagnosis of influenza under the current declared outbreak situation. Is a PRESUMPTIVE DIAGNOSIS OF INFLUENZA possible
Y
N
If after consultation with a designated representative of the Office of the MOH a presumptive diagnosis of Influenza cannot be made, NOTIFY THE CORONER’S OFFICE. If a presumptive diagnosis of Influenza CAN BE MADE
• proceed to complete this form (Section Three) and other appropriate transfer paperwork as per instructions from your MOH Office and local municipality.
• notify a local funeral home to attend to remove the body. (If the deceased has no known prior arrangements or if caregiver/family members in attendance express no specific preferences, proceed as per local municipality’s plan). Local municipalities are expected to have contingency plans in place to ensure that bodies are removed from the death scene directly to a funeral home or temporary storage facility. Death Certification and Registration will take place after body removal from the death scene.
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Ontario Health Plan for an Influenza Pandemic August 2008
Screening Questionnaire - Section Three: Note: There is no statutory requirement for who can be designated to pronounce death. It will be assumed that suitably trained screeners utilizing this form will have sufficient experience to recognize death, and by completing this section will merely be documenting a date and time for official purposes. Pronouncement of Death for: (name)___________________________________ Address:_________________________________________________________
Date:______________________________Time:_________________________
By: (Screener’s name)______________________________________________ Signature:______________________________
Coroner called: Y
N
If yes, who was contacted?___________________________Time:___________
Local funeral home contacted:
Y
N
Time:_________________
Name of funeral home:______________________________________________ Location:____________________________________________________ Contact person:_____________________________ Phone Number:_____________________________
Name of person completing this form:__________________________________ Signature: _________________________________ Telephone Number at which you can be reached:____________________
Chapter #22: Natural Death Surge Planning Strategy
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