Download ROUND ROCK MEDICAL CENTER

TSA-O
REGIONAL HOSPITAL
RESPIRATORY
PANDEMIC PLAN
Approved by the TSA-O Hospital Planning Group on August 31, 2007
TSA-O
RESPIRATORY PANDEMIC PLAN
August 31, 2007
Table of Contents
Purpose/Scope
INTERPANDEMIC PHASE
Baseline Surveillance and Respiratory Etiquette
PANDEMIC ALERT PHASE
ER Triage and Placement
Lab Procedures
PANDEMIC PHASE
Implementation of Emergency Preparedness Plan
Establishing a Dedicated Isolation Unit During a Pandemic
Traffic Control
Screening
Patient Placement and Infection Control
Inpatient
Preparation of the Isolation Area
Isolation Precautions
Standard and Droplet Precautions
Full Barrier Precautions
PPE Placement and Removal
Staffing
Procurement of Supplies and Equipment
Medical Supplies
Pharmaceuticals
Durable Medical Equipment
Waste Disposal
Environmental Cleaning and Disinfection
Visitation and Symptom Screening
Vaccination and Prophylaxis
Health Screening of Personnel
Education and Training
Communication
Public Information
Mass Casualty Management
Authority in a Public Health Emergency
Appendix A: Interim Recommendations for Infection Control in HealthCare Facilities Caring for Patients with Known or Suspected Avian Influenza
Appendix B: Updated Interim Guidance for Laboratory Testing of Persons
with Suspected Infection with Avian Influenza A (H5N1) Virus in the United
States
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1
Respiratory Pandemic Plan
Version Date: 8/31/07
PURPOSE:
This plan is the guideline for the TSA-O hospitals to provide response in the event of a
marked increase in patients due to an illness spread from person to person by respiratory
secretions. Such illness may be caused by a variety of organisms, including SARS, Avian
Flu, or a pathogen not yet identified. This outline may be used in any situation that
challenges normal operating capacity, ranging in severity from local outbreak with minimal
stress on the system to a pandemic situation creating maximum regional surge.
Information regarding specific illnesses that present current threat will be available
in the Appendix. Information provided in the appendix will be updated continually during a
critical event.
SCOPE:
In order to quickly recognize, respond to, and optimize the outcome of an influx of patients
during an outbreak, it is the goal of TSA-O hospitals to maintain a standard of care and of
vigilance at all times by:
 Quickly recognizing unusual clusters of patients presenting with similar illness and
reporting increased activity or clusters of symptoms to the local Health Department
 Maintaining strict Infection Control practices at all times to prevent the spread of
infection among patients, staff and visitors.
In the event of an influx of patients it is the policy of TSA-O hospitals to:
 Rapidly identify and isolate patients who potentially meet the case definition of
illness associated with pandemic
 Maintain communication with local, state and national health authorities
 Implement HICS Emergency Preparedness Plan and Incident Command Center, if
indicated.
DEFINITIONS:
HHS – Health and Human Services
HICS – Hospital Incident Command System
PPE – Personal Protective Equipment
HVAC – Heating, Ventilation and Air Conditioning
HCP –
EOC – Emergency Operations Center
WHO – World Health Organization
EMSystem – a web-based program that provides real-time information on hospital
emergency department diversion status, hospital patient capacity, availability of
staffed beds and available specialized treatment capabilities.
ER/ED – Emergency Room/Emergency Department
EM Bed Ready –
DSHS – Department of State Health Services
CDC – Center for Disease Control
NIMS – National Incident Management System
PHIN – Public Health Information Network
PROCEDURES:
The following procedures are organized in phases according to available information and
volume of patients presenting with symptoms. As each progressive phase is implemented,
the procedures from the preceding phase are to be continued.
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I. INTERPANDEMIC PHASE
Baseline surveillance/triage during periods of normal activity
1. Report unusual clusters of respiratory illness to Department Directors and/or
Infection Control. Infection Control will notify the County or Regional Health
Department of unusual clusters of illness.
2. Maintain “respiratory etiquette” in all intake areas of the hospital. Encourage
patients and visitors to cover their mouth when coughing or sneezing. Offer tissue
or mask. Provide alcohol hand disinfectant and tissue in waiting areas. Provide
convenient trash disposal for used tissue.
II. PANDEMIC ALERT PHASE
New virus subtypes have been identified in humans with limited person-to-person
spread. No cases reported within a 500 mile radius.
ER TRIAGE AND PLACEMENT
1.
Quickly triage and isolate any patients presenting with respiratory symptoms.
Provide a surgical mask for patient if unable to place in room immediately.
2.
Initiate Droplet Isolation precautions for patients with respiratory symptoms. Staff
should wear an N95 mask if within 3 feet of patient. Maintain strict hand hygiene
and standard precautions.
3.
If available, follow CURRENT case definition of illnesses provided by health
authorities (local Health Department or CDC) in diagnosing suspect cases. DSHS
will share case definitions and other pandemic information by fax and/or through the
Public Health Information Network. See Appendix for case definition of specific
illness, such as Avian flu.
4.
Move patients with respiratory symptoms to a room as quickly as possible. Use
rooms in new or fast track ER area which has individual rooms with permanent walls
and doors, for patients with respiratory symptoms, rather than utilizing curtained
areas.
5.
At surge capacity patients with the same diagnosis may be cohorted in the same
room, attempting to keep patients three feet apart. Maintain Droplet Isolation
Precautions.
6.
Discharge non-critical patients with instructions for infection control strategies to be
used in the home. Maintain tracking system of patients discharged. Material for
distribution can be found at: http://www.cdc.gov/flu/protect/stopgerms.htm
7.
The decision to hospitalize should be based on a clinical assessment of the
patient and the availability of hospital beds and personnel.
LAB PROCEDURES
1.
If available follow CURRENT health authority recommendations for lab testing.
(refer to Appendix for information about specific illnesses, such as Avian flu)
2.
Double bag specimens in leak proof bags to be sent to the lab and clearly label
specimen as droplet isolation source so that precautions can be taken in the lab.
3.
Personnel who transport specimens should be trained in safe handling practices
and decontamination procedures in case of a spill. Hand deliver specimens. Full
barrier PPE should be worn by HCP’s collecting specimens.
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4.
5.
Specific instructions may be issued by the Texas DSHS lab for handling and
submitting specimens during an outbreak. The contact numbers for the DSHS lab
are:
i. Virology – 512-458-7594
ii. Bacteriology and Bioterrorism – 512-458-7582
iii. Emergency/ After Hours (MD on call) – 512-458-7111
Infection Control will report cases associated with an outbreak or epidemic to the
County or Regional Health Department. Region 7 DSHS: (254) 778-6744.
III. PANDEMIC PHASE
Increased and sustained transmission in the general population, with cases reported
within a 500 mile radius.
IMPLEMENTATION OF EMERGENCY PREPAREDNESS PLAN
1.
In the event that an influx of patients with respiratory illness exceeds normal
operating capacity, the Incident Commander will determine the need to implement
the Emergency Preparedness Management Plan. The Command Center, according
to the lines of authority and responsibility outlined in the HICS plan, will be
responsible for determining the most appropriate action in the following areas:
b. Increasing bed capacity by discharging non-critical patients and
canceling elective procedures
c. Initiating call-back of available staff
d. Providing transportation and child-care for strategic staff
e. Establishing alternate triage areas and care sites
f. Restricting/screening hospital points of entry
g. Credentialing emergency medical and other volunteers
h. Implementation of mutual aid agreements and memorandums of
understanding with other entities
i. Mass fatality management
j. Medical equipment and supply availability
ESTABLISHING A DEDICATED ISOLATION UNIT DURING A PANDEMIC
If the volume of patients with the outbreak illness who require inpatient admission
exceeds current capacity or clinical symptoms indicate the need for mass isolation,
the Incident Commander may determine that it is necessary to designate portions of
the hospital to be used as an isolation area for pandemic illness patients only.
Traffic Control
1.
All entrances to the hospital will be locked, with screening stations and security
assigned to control access at the following points of entry:
a.
Emergency Ambulance Entrance – to be used for critical emergencies not
related to the respiratory pandemic. Minor emergencies will be diverted. No
one with symptoms of the pandemic illness will be allowed to enter through
this point of entry.
b.
Designated Isolation Unit– to be used as the point of entry to the isolation
area of the hospital for pandemic illness patients and family members.
2.
Barriers will be established at all points of access between the designated isolation
unit and the rest of the hospital. There will be no through traffic between the two
areas. An anteroom will be established for the delivery of supplies and food
from the main hospital to the isolation area.
3.
Staff members, physicians, and others will enter through the above entrances
according to their assigned workplace.
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Screening
1.
Screening stations will be established at each designated entry to the hospital. No
one will be allowed to enter the hospital until screened. Hospital workers reporting to
work will be given priority. No one with an elevated temperature, flu-like symptoms
or history of exposure to a suspected pandemic case will be allowed to enter
through the Emergency, Hospital, or Ambulance entrances. All persons entering
the hospital will be asked to sign in and provide contact information.
2.
All persons entering the Isolation Area will be screened for elevated temperature,
flu-like symptoms and exposure history. Those who do not pass the screening, but
are well enough to be ambulatory, will be asked to leave the hospital grounds.
Family members who pass the screening will be allowed to enter the isolation area
to care for ill patients. Those presenting as ill and unable to ambulate will be triaged
for admission to the isolation area.
PATIENT PLACEMENT AND INFECTION CONTROL
Inpatient
1.
If the volume of patients with the outbreak illness who require inpatient admission
exceeds current capacity or clinical symptoms indicate the need for mass isolation,
the Incident Commander may determine that it is necessary to designate portions of
the hospital to be used as isolation areas for outbreak illness patients only. The
following plan will be followed in TSA-O hospitals to convert inpatient wings to
isolation areas:
a.
Designated rooms will be fitted with Mintie anteroom, and ER unit fitted with
Mintie anteroom as the first designated isolation area. Begin to prepare the
other areas for potential use as additional isolation areas if volume
necessitates. Transfer patients currently on those units to other beds or
facilities, transfer to a lower level of care or discharge home if possible.
b.
When patient volume exceeds this capacity, a predetermined alternate site
may be designated as an isolation unit.
2.
Patients meeting case definition and/or definitively diagnosed with the outbreak
illness may be cohorted – placed together in patient rooms, preferably with beds
placed at least three feet apart.
3.
Maintain Droplet Isolation Precautions for all patients on the isolation unit. Doors to
patient rooms should remain closed as much as possible. If airborne transmission
is a concern, maintain full barrier precautions plus eye protection.
PREPARATION OF THE ISOLATION AREA
1.
Place a recording sheet at the entrance of the isolation room/area and have all
visitors and HCP’s entering the area sign in so that contact tracing is possible if
necessary. Visitors must provide contact information.
2.
Post signage that delineates precautions to be taken.
3.
Remove all non-essential furniture. Keep only furniture that is easy to clean and
disinfect.
4.
Stock linen as needed outside the isolation area/room.
5.
Stock hand hygiene supplies near the point of care.
6.
Provide waste bags in foot-operated bins. Provide individual patients with
conveniently located bags to dispose of tissues and other contaminated waste. A
plastic bag may be taped to the bedrail within the patient’s reach for this purpose.
7.
Keep patient’s belongings to a minimum.
8.
Non-critical patient care equipment should be dedicated to the patient.
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Set up a cart outside the door to hold PPE.
Provide an appropriate container with a lid for equipment that requires disinfection
and sterilization. Clean appropriately prior to sending to Central Sterile.
Maintain adequate equipment needed for cleaning and disinfecting the isolation
area. Provide hospital-approved disinfectants. Provide appropriate PPE for
cleaning – protective footwear, waterproof aprons and rubber gloves.
Utilize phone systems for communication between pt/family and HCP’s to minimize
necessity for HCP’s to enter the room.
Use Standard Precautions for handling dishes and eating utensils. Wash reusable
items using hospital approved procedures.
Use standard precautions for linens and other laundry contaminated with blood or
body fluids. Bag laundry inside the isolation room without shaking or agitating.
Utilized standard hospital procedures for laundering.
Engineering will separate the HVAC system of the units designated as isolation
units from the ventilation system of the other areas of the hospital.
ISOLATION PRECAUTIONS
1.
Standard and Droplet Precautions
Most respiratory illnesses are spread via the “droplet” route, by respiratory
secretions spread up to three feet by coughing, talking, sneezing, etc. In a
respiratory outbreak event standard and droplet precautions should be the minimum
level of precautions to be used. The most critical elements of these precautions
include facial protection (eyes, nose and mouth) and hand hygiene. A mask and eye
protection should be worn for close contact with the patient or during aerosolgenerating procedures.
2.
Full Barrier Precautions – Standard, Contact and Airborne (plus eye
protection)
If it is determined or suspected that the respiratory illness implicated in an outbreak
is spread through the airborne route (infectious particles stay suspended in the air
indefinitely) in addition to droplet route, the following additional actions must be
taken:
A.
Place patients with respiratory symptoms in airborne isolation in negative
pressure rooms. Patients with the same diagnosis may be cohorted in the
same rooms with the beds at least three feet apart. Request that
Engineering verify proper negative pressure.
B.
Staff must wear an N-95 mask when entering an airborne isolation room.
Only staff who have been properly fit-tested may enter isolation rooms.
C.
Staff must wear gloves and gown upon entering the room.
D.
Eye protection should be worn if close contact with the patient is anticipated
or during aerosol-generating procedures. Aerosol-generating procedures
should only be performed when absolutely essential, using the fewest
number of personnel necessary in a negative pressure room. Utilize welltrained, experienced personnel for these procedures.
E.
Place a surgical mask on the patient during transport. Only transport out of
negative pressure room when absolutely necessary. Have patient perform
hand hygiene after contact with respiratory secretions. Any surfaces
touched by the patient should be disinfected.
F.
Implement engineering controls to isolate the HVAC system and/or create
negative pressure in designated isolation areas of the hospital where
outbreak patients are being treated. Use portable engineering barriers to
isolate patients as needed for triage, treatment and/or transport.
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G.
For more information/training material refer to :
http://www.cdc.gov/ncidod/dhqp/gl_isolation_airborne.html
PPE PLACEMENT AND REMOVAL
Entering the isolation room/area:
1. Perform hand hygiene prior to donning PPE.
2. Before entering the isolation room put on PPE in the following order:
 Fluid resistant gown
 N95 Mask – perform fit check
 Hair cover if aerosol-generating procedure is performed
 Face shield or goggles
 Gloves – cover cuff of gown sleeves
3.
Enter the room and close the door
Leaving the isolation room/area:
1. Remove PPE in a manner that prevents self-contamination/inoculation with
contaminated PPE or hands. Remove PPE in an anteroom if possible, or in a
manner that ensures that the environment or other persons are not
contaminated. After leaving the isolation room, remove the PPE in the following
order:
GLOVES



Grasp outside of glove with opposite gloved hand; peel off
Hold removed glove in gloved hand
Slide fingers of ungloved hand under remaining glove at wrist
GOGGLES/FACE SHIELD



Outside of goggles or face shield are contaminated!
To remove, handle by “clean” head band or ear pieces
Place in designated receptacle
GOWN





Gown front and sleeves are contaminated!
Unfasten neck, then waist ties
Remove gown using a peeling motion; pull gown from each shoulder
toward the same hand.
Gown will turn inside out
Hold removed gown away from body, roll into a bundle and discard
receptacle.
MASK OR RESPIRATOR



Front of mask/respirator is contaminated – DO NOT TOUCH!
Grasp ONLY bottom then top ties/elastics and remove
Discard in waste receptacle (*IF critical shortage of N95 masks exists, a
surgical mask may be placed over a clean N95 mask. Discard the
surgical mask and reuse the protected N95 mask if confident that N95
mask is not contaminated.)
HAND HYGIENE

Perform hand hygiene immediately after removing all PPE!
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Reuse of N95 masks during critical shortage
1. In a critical situation there may be a shortage of masks. The following are
guidelines to allow limited reuse of an N95 mask for an individual user (not
shared use).
 Protect the mask from external surface contamination when there is a
high risk of exposure by placing a medical mask or cleanable faceshield
over the respirator so as to prevent surface contamination but not
compromise the device’s fit.
 Use and store the respirator mask in such a way that the physical
integrity and efficacy will not be compromised.
 Practice appropriate hand-hygiene before and after removal of both the
respirator and, if necessary and possible, appropriately disinfect the
object used to shield it.
STAFFING
1.
Designate dedicated staff to care for patients on the isolation units. If possible
assign experienced staff to the isolation area and do not pull assigned staff to other
areas.
2.
Consider immunity status of employees assigned (vaccination status if vaccine is
available).
3.
HCP’s who are at high risk for complications (pregnant, immunocompromised)
should be informed of the medical risks and offered alternative assignments.
4.
Limit the number of ancillary staff who enter the area to critical functions only; e.g.
provide dedicated Respiratory Therapy staff for isolation area, have nursing staff
deliver dietary trays, clean rooms and handle trash and laundry.
5.
In the event of critical staff shortages, staffing ratios may be adjusted to
accommodate as needed. Just-In-Time training may be utilized to train unlicensed
staff or volunteers to perform tasks they might not be assigned ordinarily, such as
vital signs and medical record documentation.
6.
The TSA-O Regional Credentialling Guidelines will be followed for credentialing and
privileging of licensed personnel.
PROCUREMENT OF SUPPLIES AND EQUIPMENT
1.
Medical Supplies
Hospital Materials Management will coordinate with our Distributor(s) for additional
medical supplies stocked at the local warehouse. Needs beyond the capacity of
the TSA-O facility will be addressed through a TSA-O Regional hospital M.O.M.
When resources (e.g. gloves, gowns, masks, goggles or face shields, and alcohol
hand disinfectant) are depleted during an emergency, additional supplies will be
requested through the local EOC.
2.
Pharmaceuticals
The Pharmacy maintains a 48 hour supply of critical medications including
antibiotics and antivirals. Additional medications can be obtained from local retail
pharmacies and neighboring hospitals. Emergency shipments of medications can
be ordered from wholesalers and manufacturers. In the event of a widespread
pandemic the Pharmacy Director will work with the Incident Command and local,
state and national health authorities to obtain medications such as vaccines that are
not available to the public. (see Vaccination and Prophylaxis below)
3.
Durable medical equipment
Increased needs for durable medical equipment (vents, beds, pumps) would first be
met through local vendors and/or equipment sharing between regional hospitals. If
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those sources are exhausted, Materials Management will request assistance
through the Emergency Operations Center.
WASTE DISPOSAL
Use Standard Precautions when handling waste and discarded sharps. Remove waste
from isolation areas in suitable containers or bags that do not allow for spillage or leakage
of contents. If the outside of the bag is contaminated double bag, or if bags are in short
supply, clean and disinfect the bag before removing it from the isolation room. Use gloves
when transporting waste, complete hygiene upon removal of gloves. Urine and feces can
be flushed into the sewer system if the system is not compromised – close toilet cover
when flushing.
ENVIRONMENTAL CLEANING AND DISINFECTION
1.
Cleaning must precede disinfection.
2.
Use hospital approved disinfectants known to inactivate viruses. Products with a
tuberculocidal claim are considered capable of inactivating viruses, such as
influenza. Use manufacturer’s recommendations for use/dilution, contact time and
handling.
3.
Patient rooms should be cleaned at least daily and terminally cleaned at discharge.
In addition to daily cleaning of floors and other horizontal surfaces, special attention
should be given to cleaning and disinfecting high use surfaces, such as medical
equipment, call buttons, doorknobs, faucets, rails, etc.
4.
To avoid reaerosolization perform damp-, rather than dry-dusting or sweeping. Wetdust horizontal surfaces by moistening a cloth with a small amount of disinfectant.
5.
Clean less heavily contaminated areas first and change cleaning solutions, cloths
and mop heads frequently.
6.
Use a double bucket method, with one bucket for cleaning and one for rinsing.
7.
Clean, disinfect and dry all cleaning equipment between uses. Launder mop heads
daily and dry thoroughly before storage or reuse.
8.
Wipe external surfaces of portable equipment with an approved hospital disinfectant
upon removal from the area.
VISITATION AND SYMPTOM SCREENING
1.
Visitation to isolation areas will be limited to 1 designated visitor. Visitors should be
provided with instructions on use of PPE and hand hygiene. Security may be
needed to enforce visitation restrictions. Visitors must sign-in, and will undergo the
same screening as hospital employees.
2.
Visitors with respiratory symptoms should not be allowed to enter the isolation area
and should be discouraged hospital wide. Provide surgical masks to any persons
who are coughing or sneezing.
3.
During a significant outbreak, symptom screening may be needed at hospital
entrances. If indicated, post trained staff in full barrier PPE at entrances to monitor
temperature and respiratory symptoms of those entering the hospital. Persons
identified as having symptoms should be referred for treatment as availability
indicates, preferably to their private physician. Enforce hand hygiene and
respiratory etiquette at screening points.
4.
Provide appropriate signage at entrances to restrict and direct traffic as required.
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VACCINATION AND PROPHYLAXIS
1.
Vaccination and prophylaxis, if available, will be provided to employees and medical
staff through the facility’s Employee Health and Safety Program. Non-critical
nursing staff will be utilized to provide vaccination/prophylaxis for hospital staff.
2.
In the event of a medication shortage, vaccination and prophylaxis of staff will be
prioritized according to the clinical needs of patients, targeting staff with critical skills
and qualifications necessary to provide direct care specific to the clinical needs of
the influx of patients (e.g. critical care nurses, respiratory therapy staff, medical
specialists). Depending on availability of vaccine/prophylaxis the target group will
be widened to include those providing necessary ancillary services and to family
members of critical staff.
3.
Guidelines issued by DSHS or CDC for prioritizing vaccination/prophylaxis will be
followed if available.
4.
In the event of widespread pandemic, vaccine will be distributed through the public
sector with federal and state governments controlling the purchase and distribution
during the time period when the vaccine is in short supply. The DSHS will establish
mechanisms for allocating and distributing the vaccine, with high-risk priority given
to health-care workers.
HEALTH SCREENING OF PERSONNEL
1.
Maintain a register of all personnel who have provided care for patients with the
respiratory outbreak illness.
2.
Develop a surveillance system for self-reporting and self-isolation of symptomatic
HCP’s. Each employee is to report symptoms of illness to their direct supervisor,
who will provide daily reports to Employee Health. Monitor absenteeism for those
providing care for respiratory patients.
3.
Screen all HCP’s providing care for respiratory outbreak patients before they begin
duty each day. Symptomatic HCP’s should be excluded from duty. Check
temperature twice daily and monitor for respiratory symptoms of HCP’s who care for
respiratory patients for ten days past possible exposure in an outbreak situation.
EDUCATION AND TRAINING
1.
The TSA-O Emergency Preparedness Plan entails hospital-wide training and
participation. Each department is responsible for supplementing the plan with
procedures that pertain directly to their emergency response activities and these are
included in departmental policies and procedures. Emergency preparedness
training is completed on hire and as part of annual mandatory education. Drills are
conducted periodically. Each rehearsal includes an evaluation and corrective action
to problems identified. At least one drill every year will be hospital wide and will
involve the influx and treatment of patients. The HICS Plan provides detailed
descriptions of the roles and responsibilities of each team member.
2.
Staff are trained on principles of Infection Control, including standard precautions,
isolation procedures, hand hygiene and appropriate use of personal protective
equipment, on hire and annually thereafter.
3.
An epidemic situation involving a large number of infectious patients needing
ongoing care may tax the existing resources of trained staff and require the
recruitment of care providers with unknown training status in these areas. In that
event, “just-in-time” training regarding principles of infection control will be
implemented by Infection Control and Nursing Education staff for care providers and
visitors. Posters demonstrating the appropriate donning of personal protective
equipment and respiratory etiquette will be posted at the entrances of patient care
areas. See page 17 for web links to training information and educational posters.
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COMMUNICATION
Critical channels of communication during an epidemic/pandemic include:
1.
Phone contact with the County and Regional Health Department
2.
Open communication with area hospitals
3.
PHIN (Public Health Information Network) – Texas Emergency Alert System
https://texphin.dshs.state.tx.us
4.
EMSystems – connects all hospitals and EMS to provide information regarding
bed capacity, status (green, yellow, red, black) and regional messaging.
5.
EM Bed Ready – provides regional EOC with bed availability.
6.
Communication within the hospital will be accomplished via Outlook email,
phone systems, overhead paging, hand-held radios, and runners.
7.
Infection Control will post DSHS and CDC/Health Authority updates on case
definitions, screening, laboratory procedures, treatment and guidelines for
pandemic outbreaks as they occur. This information will be posted and as an
updated Appendix to this plan.
PUBLIC INFORMATION
Communication with media will be the responsibility of the Marketing Director. Clear
communication with the public is an essential part of a health and medical response to an
epidemic/pandemic event. In order to deliver clear and appropriate messages before,
during, and after such an event, it is important to consider a number of issues:

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
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Providing consistent and regular messaging, preferably through a single
spokesperson with professional (medical) credibility, is highly desirable.
Conveying clinical information requires particular care to assure that a lay audience
can understand it. Information should be immediately relevant, without causing
undue alarm.
Distinguishing between political and professional messages is essential.
Making provisions for communication in languages other than English may be
necessary.
When possible messages should be made jointly with local, state or national health
authorities.
The Communications Unit within DSHS Center for Consumer and External Affairs is
charged with news media relations and public information dissemination during a public
health crisis.
MASS CASUALTY MANAGEMENT
TSA-O hospitals have agreements as part of the Regional MOU, providing for refrigerated
trucks that could be utilized for storing and/or transporting bodies in a mass casualty event.
If there is a delay in the availability of the trucks, the local funeral homes and hospital
basement will be utilized for storage.
AUTHORITY IN A PUBLIC HEALTH EMERGENCY
Isolation refers to the separation of persons who have a specific infectious illness from
those who are healthy and the restriction of their movement to stop the spread of that
illness. Quarantine refers to the separation and restriction of movement of persons who,
while not yet ill, have been exposed to an infectious agent and therefore may become
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infectious. Both isolation and quarantine are public health strategies that have proven
effective in stopping the spread of infectious diseases.
1. Local Authority Local governments and health departments have the primary
responsibility to provide public health, mental health and emergency medical
services within their jurisdictions. The County or Regional Health Authority will issue
recommendations regarding public safety during a health emergency. Such issues
may involve quarantine, cancellation of public events, closure of
schools/businesses, etc. The local EOC has the authority to implement the
recommendation of the Health Authority, and authorize enforcement by the local law
enforcement. In order to supplement local resources, state and federal assistance
may be available upon request or by direction of the Texas Office of Homeland
Security or the Governor’s Division of Emergency Management (GDEM).
2. State Authority The Texas Department of State Health Services (DSHS) uses the
incident Command System (ICS) structure, a component of the National Incident
Management System (NIMS). The DSHS Incident Command (IC) will be in the
DSHS Emergency Support Center (ECS) and be a part of a State and Federal
Unified Command response. The incident commander will be known as the PersonIn-Charge (PIC). The Planning and Coordination structures at the DSHS central
office, Health Service Region (HSR) offices, and local health departments (LHD) will
be unified as necessary, to assure statewide coordination is maintained and
transition between levels of authority is as seamless and as mutually agreeable as
possible.
3. National Authority Title 42 United States Code Section 264 (Section 361 of the
Public Health Service [PHS] Act) gives the Secretary of Health and Human Services
(HHS) responsibility for preventing the introduction, transmission, and spread of
communicable diseases from foreign countries into the United States and within the
United States and its territories/possessions. This statute is implemented through
regulations found at 42 CFR Parts 70 and 71. Under its delegated authority, the
Centers for Disease Control and Prevention (CDC) is empowered to detain,
medically examine, or conditionally release individuals reasonably believed to be
carrying a communicable disease.
In general, CDC defers to the state and local health authorities in the primary use of
their own separate quarantine powers. Implementation of quarantine may depend
on individual state and local health authorities as well as the characteristics (e.g.,
how widespread, who is affected) of the outbreak. However, in providing guidance
to state and local health departments and other partners, CDC would most likely
recommend voluntary home quarantine when possible, with exposed persons
checking themselves for fever and reporting early symptoms to public health
authorities. Antiviral drugs may be recommended in some situations.
12
APPENDIX A
Avian Flu
Interim Recommendations for Infection Control in Health-Care
Facilities Caring for Patients with Known or Suspected Avian
Influenza
Note: CDC is revising its interim guidance for infection control precautions for avian
influenza. The revised recommendations will be posted on the CDC website as soon as they
are finalized
Objective
This document provides interim guidance for protection of health-care workers
involved in the care of patients in the United States with known or suspected avian
influenza. Depending upon where avian influenza is active in the world, such
patients may be recently returning travelers entering U.S. health-care facilities or
individuals who have had close contact with domestic poultry infected with avian
influenza in the United States. For information regarding the clinical and
epidemiologic criteria to be used in screening patients for possible avian influenza,
see the “Update on Influenza A(H5N1) and SARS: Interim Recommendations for
Enhanced U.S. Surveillance, Testing, and Infection Control” and “Interim
Recommendations for Persons with Possible Exposure to Avian Influenza During
Outbreaks Among Poultry in the United States .”
Background
Influenza viruses that infect primarily birds are called “avian influenza viruses.”
These type A influenza viruses are genetically distinguishable from influenza
viruses that usually infect people. There are many subtypes of avian influenza A
viruses, including H7 and H5. Avian influenza viruses can be distinguished as “low
pathogenic” and “highly pathogenic” forms based on genetic features of the virus
and the severity of the illness they cause in poultry.
Avian influenza viruses do not usually infect humans; however, several instances of
human infections and outbreaks of avian influenza have been reported since 1997
(for more information, see “ Basic Information About Avian Influenza” ). In 2003,
influenza A (H7N7) infections occurred in the Netherlands among persons who
handled infected poultry and among their families during an outbreak of avian flu
among poultry. More than 80 cases of H7N7 illness were confirmed by testing (the
symptoms were mostly confined to eye infections, with some respiratory
symptoms), and one patient died (a veterinarian who had visited an H7N7 influenzaaffected farm). Although there was evidence of limited person-to-person spread of
infection, sustained human-to-human transmission did not occur in this or other
outbreaks of avian influenza. It is believed that most cases of avian influenza
infection in humans have resulted from contact with infected poultry or
contaminated surfaces. However, other means of transmission are also possible,
13
such as the virus becoming aerosolized and landing on exposed surfaces of the
mouth, nose, or eyes, or being inhaled into the lungs.
Infection and disease in people caused by highly pathogenic avian influenza H5N1
infection have been identified recently in Vietnam and Thailand. On February 1,
2004, the World Health Organization (WHO) reported that laboratory test results
had confirmed two fatal cases of human H5N1 infection in Vietnam in which humanto-human transmission may have occurred. The cases occurred in two sisters who
were part of a cluster of four cases of severe respiratory illness in a single family.
According to WHO, a detailed investigation of this cluster concluded that limited
human-to-human transmission was one possible explanation, but direct poultry-tohuman transmission could not be ruled out.
The following interim recommendations are based on what are deemed optimal
precautions for protecting individuals involved in the care of patients with highly
pathogenic avian influenza from illness and for reducing the risk of viral
reassortment (i.e., mixing of genes from human and avian viruses). The ability of
low pathogenic avian influenza viruses to cause infection and serious disease is
less well established, but appears to be lower than that of highly pathogenic viruses
based on available information. Nonetheless, it is considered prudent to take all
possible precautions to the extent feasible when caring for patients with known or
possible avian influenza.
Rationale for Enhanced Precautions
Human influenza is thought to transmit primarily via large respiratory droplets.
Standard Precautions plus Droplet Precautions are recommended for the care of
patients infected with human influenza. However, given the uncertainty about the
exact modes by which avian influenza may first transmit between humans additional
precautions for health-care workers involved in the care of patients with
documented or suspected avian influenza may be prudent. The rationale for the use
of additional precautions for avian influenza as compared with human influenza
include the following:



The risk of serious disease and increased mortality from highly pathogenic
avian influenza may be significantly higher than from infection by human
influenza viruses.
Each human infection represents an important opportunity for avian influenza
to further adapt to humans and gain the ability to transmit more easily among
people.
Although rare, human-to-human transmission of avian influenza may be
associated with the possible emergence of a pandemic strain.
14
Recommendations for Avian Influenza
All patients who present to a health-care setting with fever and respiratory
symptoms should be managed according to recommendations for Respiratory
Hygiene and Cough Etiquette and questioned regarding their recent travel history.
Patients with a history of travel within 10 days to a country with avian influenza
activity and are hospitalized with a severe febrile respiratory illness, or are
otherwise under evaluation for avian influenza, should be managed using isolation
precautions identical to those recommended for patients with known Severe Acute
Respiratory Syndrome (SARS). These include:




Standard Precautions
o Pay careful attention to hand hygiene before and after all patient
contact or contact with items potentially contaminated with respiratory
secretions.
Contact Precautions
o Use gloves and gown for all patient contact.
o Use dedicated equipment such as stethoscopes, disposable blood
pressure cuffs, disposable thermometers, etc.
Eye protection (i.e., goggles or face shields)
o Wear when within 3 feet of the patient.
Airborne Precautions
o Place the patient in an airborne isolation room (AIR). Such rooms
should have monitored negative air pressure in relation to corridor,
with 6 to 12 air changes per hour (ACH), and exhaust air directly
outside or have recirculated air filtered by a high efficiency particulate
air (HEPA) filter. If an AIR is unavailable, contact the health-care
facility engineer to assist or use portable isolation anterooms (Mintie)
with HEPA filters (see Environmental Infection Control Guidelines) to
augment the number of ACH.
o Use a fit-tested respirator, at least as protective as a National Institute
of Occupational Safety and Health (NIOSH)-approved N-95 filtering
facepiece (i.e., disposable) respirator, when entering the room.
For additional information regarding these and other health-care isolation
precautions, see the Guidelines for Isolation Precautions in Hospitals. These
precautions should be continued for 14 days after onset of symptoms or until either
an alternative diagnosis is established or diagnostic test results indicate that the
patient is not infected with influenza A virus. Patients managed as outpatients or
hospitalized patients discharged before 14 days with suspected avian influenza
should be isolated in the home setting on the basis of principles outlined for the
home isolation of SARS patients (see
http://www.cdc.gov/ncidod/sars/guidance/i/pdf/i.pdf).
15
Vaccination of Health-Care Workers against Human Influenza
Health-care workers involved in the care of patients with documented or suspected
avian influenza should be vaccinated with the most recent seasonal human
influenza vaccine. In addition to providing protection against the predominant
circulating influenza strain, this measure is intended to reduce the likelihood of a
health-care worker’s being co-infected with human and avian strains, where genetic
rearrangement could take place, leading to the emergence of potential pandemic
strain.
Surveillance and Monitoring of Health-Care Workers




Instruct health-care workers to be vigilant for the development of fever,
respiratory symptoms, and/or conjunctivitis (i.e., eye infections) for 1 week
after last exposure to avian influenza-infected patients.
Health-care workers who become ill should seek medical care and, prior to
arrival, notify their health-care provider that they may have been exposed to
avian influenza. In addition, employees should notify occupational health and
infection control personnel at their facility.
With the exception of visiting a health-care provider, health-care workers who
become ill should be advised to stay home until 24 hours after resolution of
fever, unless an alternative diagnosis is established or diagnostic tests are
negative for influenza A virus.
While at home, ill persons should practice good Respiratory Hygiene and
Cough Etiquette to lower the risk of transmission of virus to others.
Respirators should be used in the context of a complete respiratory protection
program as required by the Occupational Safety and Health Administration (OSHA).
This includes: training, fit-testing, and fit-checking to ensure appropriate respirator
selection and use. To be effective, respirators must provide a proper sealing surface
on the wearer's face. Detailed information on a respiratory protection program is
provided at this OSHA web page.
Links and Resources:
http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
http://www.cdc.gov/flu/professionals/infectioncontrol/healthcarefacilities.htm
http://www.cdc.gov/flu/protect/pdf/covercough_hcp8-5x11.pdf
http://www.cdc.gov/flu/protect/espanol/pdf/covercough_hcp8-5x11span.pdf
http://www.cdc.gov/ncidod/dhqp/pdf/ppe/ppeposter148.pdf
http://www.cdc.gov/ncidod/dhqp/gl_isolation_airborne.html
16
www.cdc.gov/flu/avian
www.cdc.gov/flu/avian/professional/
www.pandemicflu.gov/
www.dshs.state.tx.us/idcu/disease/influenza/pandemic/Draft
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5505a3.htm
17
APPENDIX B
Distributed via Health Alert Network
Wednesday, June 07, 2006, 19:50 EDT (7:50 PM EDT)
CDCHAN-00246-2006-06-07-UPD-N
Updated Interim Guidance for Laboratory Testing of Persons
with Suspected Infection with Avian Influenza A (H5N1) Virus in
the United States
CDC Health Update
This update provides revised interim guidance for testing of
suspected human cases of avian influenza A (H5N1) in the United
States and is based on the current state of knowledge regarding
human infection with H5N1 viruses. The epidemiology of H5N1
human infections has not changed significantly since February
2004. Therefore, CDC recommends that H5N1 surveillance in the
United States remain at the enhanced level first established at that
time. However, this revised interim guidance provides an updated
case definition of a suspected H5N1 human case for the purpose of
determining when testing should be undertaken and also provides
more detailed information on laboratory testing. Effective
surveillance will continue to rely on health care providers obtaining
information regarding international travel and other exposure risks
from persons with specified respiratory symptoms as detailed in the
recommendations below. This guidance will be updated as the
epidemiology of H5N1 changes. Note: CDC is revising its interim
guidance for infection control precautions for avian influenza A
(H5N1). These will be issued as soon as they are available.
Current Situation
The avian influenza A (H5N1) epizootic (animal outbreak) in Asia
has expanded to wild birds and/or poultry in parts of Europe, the
Near East and Africa. Sporadic human infections with H5N1
continue to be reported and have most recently occurred in China,
Egypt, Indonesia, Azerbaijan, Cambodia, and Djibouti. In addition,
rare instances of probable human-to-human transmission
associated with H5N1 viruses have occurred, most recently in a
family cluster in Indonesia. So far, however, the spread of H5N1
virus from person to person has been rare, inefficient, and
unsustained. The total number of confirmed human cases of H5N1
reported as of June 7, 2006 has reached 225. The case fatality rate
for these reported cases continues to be approximately 50 percent.
As of this date, H5N1 has not been identified among animals or
humans in the United States.
18
The epizootic in Asia and parts of Europe, the Near East and Africa
is not expected to diminish significantly in the short term and it is
likely that H5N1 infection among birds has become enzootic in
certain areas. It is expected that human infections resulting from
direct contact with infected poultry will continue to occur in affected
countries. Since no sustained human-to-human transmission of
influenza H5N1 has been documented anywhere in the world, the
current phase of alert, based on the World Health Organization
(WHO) global influenza preparedness plan, remains at Phase 3
(Pandemic Alert).* In addition, no evidence for genetic
reassortment between human and avian influenza A virus genes
has been found. Nevertheless, this expanding epizootic continues
to pose an important and growing public health threat. CDC is in
communication with WHO and other national and international
agencies and continues to monitor the situation closely.
Reporting and Testing Guidelines
CDC recommends maintaining the enhanced surveillance efforts
practiced currently by state and local health departments, hospitals,
and clinicians to identify patients at increased risk for avian
influenza A (H5N1). Guidance for enhanced surveillance was first
described in a HAN update issued on February 3, 2004 and most
recently updated on February 4, 2005.
Testing for avian influenza A (H5N1) virus infection is recommended
for:
A patient who has an illness that:
§
requires hospitalization or is fatal; AND
§
has or had a documented temperature of ≥38°C (≥100.4°
F); AND
§
has radiographically confirmed pneumonia, acute
respiratory distress syndrome (ARDS), or other severe respiratory
illness for which an alternate diagnosis has not been established;
AND
§
has at least one of the following potential exposures within
10 days of symptom onset:
A)
History of travel to a country with influenza H5N1
documented in poultry, wild birds, and/or humans,† AND had at
least one of the following potential exposures during travel:
•
direct contact with (e.g., touching) sick or dead domestic
poultry;
•
direct contact with surfaces contaminated with poultry feces;
•
consumption of raw or incompletely cooked poultry or
poultry products;
•
direct contact with sick or dead wild birds suspected or
confirmed to have influenza H5N1;
•
close contact (approach within 1 meter [approx. 3 feet]) of a
19
person who was hospitalized or died due to a severe unexplained
respiratory illness;
B)
Close contact (approach within 1 meter [approx. 3 feet]) of
an ill patient who was confirmed or suspected to have H5N1;
C)
Worked with live influenza H5N1 virus in a laboratory.
Testing for avian influenza A (H5N1) virus infection can be
considered on a case-by-case basis, in consultation with local and
state health departments, for:
•
A patient with mild or atypical disease‡ (hospitalized or
ambulatory) who has one of the exposures listed above (criteria A,
B, or C); OR
•
A patient with severe or fatal respiratory disease whose
epidemiological information is uncertain, unavailable, or otherwise
suspicious but does not meet the criteria above (examples include:
a returned traveler from an influenza H5N1-affected country whose
exposures are unclear or suspicious, a person who had contact with
sick or well-appearing poultry, etc.)
Clinicians should contact their local or state health department as
soon as possible to report any suspected human case of influenza
H5N1 in the United States.
Specimen Collection and Testing Guidelines
§
Oropharyngeal swab specimens and lower respiratory tract
specimens (e.g., bronchoalveolar lavage or tracheal aspirates) are
preferred because they appear to contain the highest quantity of
virus for influenza H5N1 detection, as determined on the basis of
available data. Nasal or nasopharyngeal swab specimens are
acceptable, but may contain less virus and therefore not be optimal
specimens for virus detection.
§
Detection of influenza H5N1 is more likely from specimens
collected within the first 3 days of illness onset. If possible, serial
specimens should be obtained over several days from the same
patient.
§
Bronchoalveolar lavage is considered to be a high-risk
aerosol-generating procedure. Therefore, infection control
precautions should include the use of gloves, gown, goggles or face
shield, and a fit-tested respirator with an N-95 or higher rated filter.
A loose-fitting powered air-purifying respirator (PAPR) may be used
if fit-testing is not possible (for example, if the person has a
beard). Detailed guidance on infection control precautions for health
20
care workers caring for suspected influenza H5N1 patients is
available.||
§
Swabs used for specimen collection should have a Dacron
tip and an aluminum or plastic shaft. Swabs with calcium alginate or
cotton tips and wooden shafts are not recommended.§ Specimens
should be placed at 4°C immediately after collection.
§
For reverse-transcriptase polymerase chain reaction (RTPCR) analysis, nucleic acid extraction lysis buffer can be added to
specimens (for virus inactivation and RNA stabilization), after which
specimens can be stored and shipped at 4°C. Otherwise,
specimens should be frozen at or below -70°C and shipped on dry
ice. For viral isolation, specimens can be stored and shipped at
4°C. If specimens are not expected to be inoculated into culture
within 2 days, they should be frozen at or below -70°C and shipped
on dry ice. Avoid repeated freeze/thaw cycles.
§
Influenza H5N1-specific RT-PCR testing conducted under
Biosafety Level 2 conditions is the preferred method for diagnosis.
All state public health laboratories, several local public health
laboratories, and CDC are able to perform influenza H5N1 RT-PCR
testing, and are the recommended sites for initial diagnosis.
§
Viral culture should NOT be attempted on specimens from
patients suspected to have influenza H5N1, unless conducted
under Biosafety Level 3 conditions with enhancements.
§
Commercial rapid influenza antigen testing in the evaluation
of suspected influenza H5N1 cases should be interpreted with
caution. Clinicians should be aware that these tests have relatively
low sensitivities, and a negative result would not exclude a
diagnosis of influenza H5N1. In addition, a positive result does not
distinguish between seasonal and avian influenza A viruses.
§
Serologic testing for influenza H5N1-specific antibody,
using appropriately timed specimens, can be considered if other
influenza H5N1 diagnostic testing methods are unsuccessful (for
example, due to delays in respiratory specimen collection). Paired
serum specimens from the same patient are required for influenza
H5N1 diagnosis: one sample should be tested within the first week
of illness, and a second sample should be tested 2-4 weeks later. A
demonstrated rise in the H5N1-specific antibody level is required for
a diagnosis of H5N1 infection. Currently, the microneutralization
assay, which requires live virus, is the recommended test for
measuring H5N1-specific antibody. Any work with live wild-type
highly pathogenic influenza H5N1 viruses must be conducted in a
USDA-approved Biosafety Level 3 enhanced containment facility.
21
Visit http://www.cdc.gov/flu/h2n2bsl3.htm for more information about
procedures and facilities recommended for manipulating highly
pathogenic avian influenza viruses.
Laboratory testing results positive for influenza A (H5N1) in the
United States should be confirmed at CDC, which has been
designated as a WHO H5 Reference Laboratory. Before sending
specimens, state and local health departments should contact
CDC’s on-call epidemiologist at (404) 639-3747 or (404) 639-3591
(Monday – Friday, 8:30 AM - 5:00 PM) or (770) 488-7100 (all other
times).
Travel Health Notice
CDC has not recommended that the general public avoid travel to
any of the countries affected by H5N1. However, CDC does
recommend that travelers to these countries avoid poultry farms and
bird markets or other places where live poultry are raised or kept.
For details about other ways to reduce the risk of infection, see
http://www.cdc.gov/travel/other/avian_influenza_se_asia_2005.htm.
More Information
Department of Health and Human Services at www.pandemicflu.gov
World Health Organization at
World Organization for Animal Health (OIE) at
http://www.oie.int/eng/en_index.htm
*For the current WHO Pandemic Phase, see
http://www.who.int/csr/disease/avian_influenza/phase/en/index.html.
† For a listing of influenza H5N1-affected countries, visit the CDC
website at http://www.cdc.gov/flu/avian/outbreaks/current.htm; the
OIE website at http://www.oie.int/eng/en_index.htm; and the WHO
website at http://www.who.int/csr/disease/avian_influenza/en/.
‡ For example, a patient with respiratory illness and fever who does
not require hospitalization, or a patient with significant neurologic or
gastrointestinal symptoms in the absence of respiratory disease.
|| Interim recommendations for infection control in health-care
facilities caring for patients with known or suspected avian influenza
are available at http://www.cdc.gov/flu/avian/professional/infectcontrol.htm.
§ Specimens can be transported in viral transport media, Hanks
balanced salt solution, cell culture medium, tryptose-phosphate
broth, veal infusion broth, or sucrose-phosphate buffer. Transport
media should be supplemented with protein, such as bovine serum
albumin or gelatin, to a concentration of 0.5% to 1%.
22
Information regarding Laboratory Biosafety Level Criteria can be
found at http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4s3.htm.

##This Message was distributed to State and Local Health Officers,
Public Information Officers, Epidemiologists, State Laboratory
Directors, Weapons of Mass Destruction Coordinators and HAN
Coordinators, as well as Public Health Associations and Clinician
organizations##
Categories of Health Alert Messages:
Health Alert Conveys the highest level of importance; warrants
immediate action or attention.
Health Advisory
Provides important information for a specific
incident or situation; may not require immediate
action.
Health
Provides updated information regarding an
Update
incident or situation; unlikely to require immediate
action.
WHO Rapid Advice Guidelines on pharmacological management of humans
infected with avian influenza (H5N1) virus, 2006 (1.9 MB/138 pages)
23