Download Appendix 4: Planning Assumptions

Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Table of Contents:
1. Plan Background / Review
2. Goals
3. Planning Assumptions
4. Decision-making structures for response
5. Hospital surveillance
6. Communication
7. Infection control
a.
b.
c.
d.
e.
Standard Precautions
Isolation Precautions
Visitors
Cleaning, Disinfection and Sterilization
Environmental Cleaning
8. Education and training
9. Patient triage
a. Home Discharge Instructions
10. Clinical guidelines
11. Use, administration and of vaccines and antiviral drugs
12. Surge capacity
a. Staffing
b. Supplies
c.
Rooms
13. Mortuary issues
14. Security/facility access
15. Human Resource Issues
a. Staffing
b. Occupational health
16. Recovery of operations
17. Contacts - Authority and Responsibility
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendices (List of documents already available for use)
Appendix ?? : Preparing for Selected Associates to Work From Home
Appendix ?? : Protocol for Employees who become ill
Appendix ?? Suspect Influenza Case Form -Management of Associates Who Become Ill at Work
Appendix ?? An Employee with Influenza-like Illness (ILI) Assessment Tool
Appendix ?? : Infection Control Procedures
Appendix ?? : Algorithm 1: Pandemic Influenza in Adults
Appendix ?? : Algorithm 2: Pandemic Influenza in Children
Appendix ?? : Algorithm 3: Pandemic Influenza Complications
Appendix ?? : Scoring criteria for the Sequential Organ-Failure Assessment (SOFA) score*
Appendix ?? : Criteria for Identifying the Appropriateness of Critical Care
Appendix ?? : Clinical Triage Guidelines
Appendix ?? : CDC Case Report Form
Appendix ?? : Home Discharge Instructions
Appendix ?? : Standard Protocol Order Form : Influenza Like Illness
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
1. Background / Review of Plan
This plan provides infection prevention and control guidance for the management of pandemic influenza at Saint
Elizabeth Regional Medical Center (SERMC). Its development required collaboration between many departments of
the Medical Center, as well as the input of community entities. It is the accumulation of the recommendations of
many hospitals and community health agencies throughout the world.
Although recommendations to prevent the transmission of infection during the delivery of health care, including
during a pandemic are important, it is recognized that certain recommendations may be feasible only in the early
phases of the pandemic as they may not be achievable when the pandemic spreads and resources become scarce.
This plan is an ever-developing document, and will be reviewed at least every 3 years, and updated as frequently
as needed according to current legislation and relevant publications.
Medical Center Management and associates are educated about relevant portions of the plan and drills are
conducted as needed to ensure the ability of the Medical Center to carry out the plan.
Pandemic Influenza Plan Triggers
Based on the WHO description of Pandemic Phases and implemented by the LLCHD, SERMC will be affected in
each phase within the Plan depending upon whether human infection is occurring within the local region.
The resource used for defining the current Pandemic Phase is the World Health Organization (WHO)
http://www.who.int/csr/disease/avian_influenza/phase/en/index.html Responsibility for remaining abreast of the
current world situation is assigned. (See Appendix ..)
Pandemic Phases
Possible SERMC Response Actions
Interpandemic
Phase
New virus in
animals, no
human cases
Pandemic Alert
New virus
causes human
cases
Phase 1
(low risk of human cases)
Phase 2
(higher risk of human cases)



Conduct planning
Conduct education/training
Conduct hospital surveillance for influenza
Phase 3
(no or very limited human-tohuman transmission)






Preparedness planning with partners
Business continuity planning
Educate response staff
Initiate stockpile of antiviral medications and essential supplies
Continue hospital surveillance for influenza
Influenza and respiratory illness outbreaks should be reported
immediately by phone to LLCHD 441-8000.
Influenza-related pediatric ICU cases and pediatric deaths should
be reported by phone, as soon as possible after laboratory
confirmation of influenza to LLCHD 441-8000..
Implement screening tool for Identification Isolation of potential
cases (See appendix ??)
Implement a system for early detection and treatment of
healthcare workers (See appendix ??)
Reinforce Infection Control practices (See appendix ??)
Quarantine of close contacts / occupational exposure
Increase supplies of : Hand hygiene agents, disposable masks,
face shields, gowns, gloves, tissues, central line kits, morgue
packs, ventilators, IV pumps, beds and respiratory care
equipment)
Monitor census / staffing
Post signs for respiratory hygiene/cough etiquette

Phase 4
(evidence of increased humanto-human transmission)







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Pandemic
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Phase 5
 Implement social distancing program
(evidence of significant human-  Implement emergency staffing plans
to-human transmission)
 Reduce access to elective admission and surgery
Phase 6
Emergency Department
(efficient and sustained human-  Establish segregated waiting areas for patients with influenza
to-human transmission)
symptoms
 Implement phone triage to discourage ED/Outpatient visits
 Enforce respiratory hygiene/cough etiquette
Access Controls
 Limit number of visitors
 Screen visitors for signs & symptoms of influenza
 Limit points of entry to facility
Hospital Admissions
 Defer elective admissions and procedures
 Discharge patients as soon as possible
 Cohort patients admitted with influenza
 Monitor for nosocomial transmission
Staffing Practices
 Consider reassignment of pregnant & staff at high risk for
complications of influenza
 Cohort staff caring for influenza patients
 Consider assigning staff recovering from influenza to care for
influenza patients
 Implement system for detection and reporting signs & symptoms
of influenza in staff reporting for duty
 Provide staff with antiviral prophylaxis, according to HHS
recommendations
 Close units where there has been nosocomial transmission
 Cohort staff and patients
 Restrict new admissions to affected units
 Restrict visitors
 Redirect personnel resources to support patient care
 Recruit community volunteers
 Consider work-at-home program for all non-essential personnel
who cannot be reassigned to support critical hospital services
Nosocomial transmission
As above, plus, if nosocomial transmission is limited to only a small
number of units in the facility,

Widespread transmission in
community and hospital;
patient admissions at surge
capacity
Close units where there has been nosocomial
transmission.
 Cohort staff and patients.
 Restrict new admissions (except for other pandemic
influenza patients) to affected units.
 Restrict visitors to the affected units to those who are
essential for patient care and support.
As above plus: Redirect personnel resources to support patient
care (e.g., administrative clinical staff, clinical staff working
in departments that have been closed [e.g.,
physical/occupational therapy, cardiac catheterization]).

Recruit community volunteers (e.g., retired nurses and
physicians, clinical staff working in outpatient settings).
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07

Consider placing on administrative leave all non-essential
personnel who cannot be reassigned to support critical
hospital services.
2. Goals of this plan
During a pandemic impacting Lincoln-Lancaster County, all efforts will be employed to sustain the functionality of
Saint Elizabeth health care system while maintaining an acceptable level of medical care. In order to accomplish
this, Saint Elizabeth Regional Medical Center has the following goals:
1. Conduct enhanced surveillance for influenza-like illness (ILI) among patients, staff and visitors.
a. Remain abreast of current government definitions and requirements.
b. Comply with public health orders for detecting, preventing and reporting cases of pandemic flu.
2. Implement appropriate infection control measures.
3. Develop and provide education and training to healthcare staff on appropriate aspects of pandemic influenza.
4. Maintain availability of services
a. Limit the provision of health care services to patients with urgent, health problems requiring
hospitalization;
b. Provide alternative mechanisms for patients to address non-urgent health care needs such as
telephone and internet-based consultation.
5. Respond to hospital and acuity surge
a. Increase hospital bed capacity to care for large numbers of influenza patients;
b. Implement pandemic-specific patient triage and management procedures;
6. Modify staffing and standards of care
a. Mobilize, reassign and deploy staff within the Medical Center to address critical shortfalls;
b. Provide for the health and safety of associates and their families.
c. Develop and communicate acceptable, though reduced, standards of care appropriate to emergency
situations.
3. Planning Assumptions
Disease:
The specific nature of the organism / disease causing pandemic will not be known until evaluation of the first
cases. Until determined to be different, decisions regarding disease transmission will be based on characteristics of
seasonal influenza
 Directly transmitted primarily by droplet contact of the oral, nasal, or possibly conjunctival mucous membranes
with the oropharyngeal secretions of an infected individual.
 Indirectly transmitted from hands and objects freshly soiled with discharges of the nose and throat of an
acutely ill and coughing individual.
 Incubation period 1-3 days.
 Period of Communicability: Infectious 1 day before onset of symptoms and may be longer than 7 days after the
onset of symptoms.
Attack rate:
 Susceptibility to the pandemic influenza subtype will be universal prior to vaccination. The only people assumed
to be immune are
o individuals who have recovered from the pandemic strain of influenza.
o individuals who have been vaccinated against the pandemic strain of influenza. (Because influenza
vaccines are not 100% efficacious, if vaccinated individuals come in contact with influenza patients, the
vaccinated individual should be monitored for ILI using the ILI Assessment Tool).
 The clinical disease attack rate is estimated to be 30 percent of the population.
 Illness rates will be the highest among school-aged children (approximately 40 percent) and decline with age.
 The pandemic may last up to 18 months and several waves are likely.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Healthcare utilization:
Healthcare providers must be prepared to manage a surge of pandemic influenza patients presenting for care
based on general predictions from the U.S. Department of Health and Human Services and based on current data
of influenza outbreaks.

Fifty percent of ill persons will seek outpatient medical care.

Hospitalization will be required for a large number of those severely ill. Length of stay will be 4, 7 and 8
days for the 0-17, 18-64, and 65+ year age groups, respectively

An average of two secondary infections will occur per infected person.

Infection control needs will expand and change as an influenza pandemic evolves.

A vaccine for the pandemic influenza strain will likely not be available for 6 to 8 months following the
emergence of a novel virus.

SERMC and SEPN will have to modify their operational structure to respond to high patient volumes and
maintain functionality of critical systems.

When hospital capacity is exceeded, Influenza Care Centers will be provided through the Emergency
Operations Center, for patients who can safely be cared for outside the acute care setting; hospitalization
will be reserved for patients needing the most sophisticated care.

Demand for inpatient beds and assisted ventilators will increase by 25% or more, and prioritization criteria
for access to limited services and resources may be needed.

We will not be able to rely on mutual aid resources or rental supplies and equipment, State or Federal
assistance to provide care, with the following exceptions:
o
Veteran’s Administration Medical Center – accessed through the Emergency Operations Center
o
?? – access through the Emergency Operations Center
Staffing:
The attack will limit the number of healthcare personnel available to care for patients and may affect the
availability of supplies and other services.

About 20 percent of working adults will be affected.

People may be asymptomatic while infectious and the incubation period may be as little as two days, the
same as with seasonal influenza.

Viral shedding will occur one-half to one day prior to the onset of illness.

Shedding will be the heaviest in the first two days after symptoms develop.
Capacity for providing care: (See Capacity Management Plan – Administrative Manual)

Normal capacity is 184 patients; high census = greater than 240 patients

A bed shortage occurs when multiple patients are waiting for an inpatient bed and/or beds on an
appropriate unit and the beds are unavailable due to a high census situation. e.g., two or more patients
are waiting for a bed assignment in the Emergency Department (ED), Post Anesthesia Care Unit (PACU),
Labor and Delivery (L&D), or direct admissions and no beds are anticipated for two or more hours

Number of ventilators in-house: 24 conventional, universal ventilators in-house. Rental of additional
ventilators will be difficult.
Situations which will impact capacity

Availability of Utilities : power, water, gases, medical gases

Ability to divert patients (directed to EOC)

Cases will occur in the world weeks to months prior to occurring in Lincoln

Ability to alter traditional standards of care to maximize healthcare resources and achieve the optimal
benefit for the most people, i.e. “Sufficiency of care,” medical care that may not be of the same quality as
that delivered under non-emergency conditions but that is sufficient for need, may be the standard of care
during an influenza pandemic.

Effect and availability of immunization and anti-flu viral agents

Reduced capacity related to staff / family infection (15-30% staff absence)

Sustainability of response >12 weeks

Major increase in admission for non-pneumonic respiratory disease, e.g., COPD, bronchitis, and heart
failure
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
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Staffing will be the limiting factor to capacity
o Surge response decisions made by Incident Command are based on data regarding both bed and
staff availability. (See table I)
o Departments will have plans identifying
 basic and surge staffing
 basic and “optional” service levels
 decision-making structure for absences of key decision-makers
o Under specific emergency conditions, volunteers, retired healthcare professionals, and trained
unlicensed personnel may be used to provide patient care in a variety of settings.
o Current resources for mass fatality care at all levels, including healthcare facilities, the county
morgue and mortuaries, may be inadequate to meet the challenges posed by pandemic influenza.
4. Decision-making Processes
1. The Hospital Incident Command System (HICS) is the decision-making structure used by SERMC for a
sustained continuity of hospital operations and patient care services.
2. SERMC Administration should consider early activation of HICS to manage the pandemic’s impact on their
organization.
3. Pandemic influenza planning strategies incorporate current local, state and federal guidance.
4. Implementation of the Pandemic Plan - SERMC will implement their Pandemic Response Plan upon either the
notification of LLCHD, or the awareness of a sudden surge of influenza patients during the initial phases of the
pandemic within the United States. Coordination between levels of government, in Nebraska, will be
accomplished through utilization of Health Alert Network.
At each phase of the Pandemic, based on patient census and staffing levels, the Incident Command team makes
decisions about available services and designates appropriate resources. Implementation plans are available for
each of the decisions to be made.
Table I - Surge Capacity Decision-Making – Guide for the Incident Command Team
X
X
X
X
X
X
X
X
X
X
X
X
X
Implement rapid discharge
plan
Implement cross-training
Request Ethics Committee
input
Implement Incentive Pay
Program
Cohort patients / quarantine
units
Rapid Hire process
X
X
X
X
X
X
X
X
X
Designate a morgue area
X
X
X
X
X
X
X
Encourage Family Care
Activate Access Control
Discontinue Rehab PT
X
X
X
X
X
X
X
X
X
X
X
Work-from-home
X
X
X
X
X
X
X
Implement Patient triage
and controlled admission
X
Cancel Elective Surgery
Staffing availability
Activate Labor Pool
X
X
X
X
X
X
X
Implement visitor
Surveillance and restriction
Level 3:
Adeq
Inadeq
Adeq
Inadeq
Adeq
Inadeq
Inventory Surge Supplies
and Equipment
Level 2:
202
Decisions to be made by Incident Command Team
Cancel Elective Admissions
Level 1:
Some acuity measure
Basis of decisionmaking
Patient Census
SERMC
Surge
Level
X
X
X
X
X
X
X
X
X
X
X
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
5. Surveillance System
SERMC plays an essential role in surveillance for suspected cases of infection with novel strains of influenza. Novel
strains may include avian or animal influenza strains that can infect humans (like avian influenza A [H5N1]) and
new or re-emergent human viruses that cause cases or clusters of human disease. Surveillance includes: 1)
patients, 2) visitors, and 3) associates.
SERMC’s surveillance plan includes:







Laboratory participation with the local public health as a sentinel lab to monitor influenza activity
throughout the county/district health departments. (?)
 Participation, as requested, in the developing national Bio-Sense system
(http://www.cdc.gov/mmwr/preview/mmwrhtml/su5401a4.htm)
 Provide to local or state health department information on ED visits, admissions, and deaths as requested
Updated information on the types of data that should be reported to the health departments and
plans for how these data will be collected during a pandemic will be provided by the LincolnLancaster County Health Department.
 Syndromic surveillance (i.e. patients presenting with Influenza Like Illnesses (ILI) of patients presenting to
the emergency department and other key first contact departments. Local county health departments
during an Alert may request this information. (See Appendix ?: CDC Human Influenza A (H5) Case Screen
and Report Form)
Case definition of an ILI and management of these cases. ( See Appendix 6: Case Detection and Clinical
Management During the Inter-Pandemic Alert Periods)
Syndromic surveillance program for ILI of employees. (See Occupational Health Section)
Facilitate the collection and testing of appropriate specimens as recommended for early detection of pandemic
virus at the local level. (See Laboratory Utilization Section)
Mechanisms for conducting surveillance in emergency departments to detect any increases in influenza-like
illness during the early stages of the pandemic
Monitor of health care associated infection (HAI) transmission of pandemic cases.
Mechanisms for monitoring employee absenteeism for increases that might indicate early cases of pandemic
influenza
Patients
Two types of pandemic influenza reporting may occur, case-level reporting and batch reporting, with batch
reporting more likely as transmission increases and the pandemic spreads.
1. No cases of pandemic influenza have been identified in Lancaster County - When the World Health
Organization declares a worldwide pandemic, vigorous enhanced surveillance by individual health care
providers and aggressive testing of suspect cases to identify infections with the pandemic strain and control its
spread must occur.
2. Pandemic strain has been identified in Lancaster County; widespread person-to-person transmission is
occurring,
The surveillance goals during a pandemic will be to:
1. Identify affected patients for triage. If admission is required, admit to the cohort unit appropriate to the
level of care required.
2. Identify affected staff to be triaged to one of three dispositions: 1) fit-for-work 2) unfit-for-work, or 3) fit
for restricted work.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Staff
Pandemic
The SERMC mechanism for screening associates working in the building for early cases of pandemic influenza
includes use of a screening tool (See Appendix ?? ILI Screening Tool). Staff who are fit-for-work…
Pregnant staff who are not immune...
6. Communication
Handling calls from general public:
 PR/Marketing has plan in place for responding to house-wide needs to communicate with general public via
media and communicating with media [attached]
 Use TLC and/or CARE for answering calls from general public (switchboard is not set up for mass calls and
TLC and CARE have up to 12 phones and have tracking capability) about whether a patient is here/who
has vaccine/where to get info/etc.
 TLC has scripting for a variety of scenarios from “we have no information yet” to directing callers to
websites or clinics [attached]
Contact information for key persons inside and outside the facility is being drawn up. (under development)
 PR/Marketing has departmental list of cell phone numbers of staff so they will not need to tie up medical
center phones and for rapid response
 Email addresses
Website for ongoing communication with general public/media/physician partners/associates not in-house
The Saint Elizabeth Internet [www.SaintElizabethOnline.com] has been established as the primary means for
updating the public, media, physician partners as well as our Saint Elizabeth associates who are either working
from home or for various reasons not in the workplace.
General Public:
 Factual information on the pandemic [numbers affected/what the health dept is doing/what’s going on at
Saint E/etc]
 Factual information on the disease [symptoms, when contagious/etc]
 Guidelines for providing care at home/When to contact a doctor/etc
 Info on our SEPN clinics---who is open; who has vaccine; who is offering special services (if any)
 Who in the city or area has vaccine
 How to talk to children
 FAQs
 Links to helpful websites such as CDC, health department, etc. AND pages on our site that are copies of
some of the most useful info from key sites---the websites themselves maybe overwhelmed with traffic
and access can become impossible.
For media:
 Details as to when & where the next news conference is scheduled.
 List of phone numbers of appropriate people to contact at Saint Elizabeth.
 Email links so media can request info or interviews.
 Updated data from Saint Elizabeth (# patients affected, etc.)
 Possible photos or video they can use on air or in print.
 Possible video interviews with physicians or other medical personnel
 Useful info for community such as factual info on the pandemic/the illness/check lists of supplies needed
for survival at home 1 week/2 weeks/etc
 Links to helpful websites such as CDC, health department, etc. AND pages on our site that are copies of
some of the most useful info from key sites---the websites themselves maybe overwhelmed with traffic
and access can become impossible
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
For associates:
 Special web areas are available for associates such as blogs for department-specific information—
chronological messages re: current staffing levels, department needs, isolation, etc. Comment areas are
included on the blogs for questions or other comments and email will be available right form the blog so
staff at home can let their department know they will not be in at regular shift time but can come in from
2am –noon, etc.
 Information on the next transport shuttle picking up/dropping off staff as well as locations & maps---and
an area for at-home staff to sign-up for the shuttle routes, etc.
 Links to websites such as CDC, health department, etc. AND pages on our site that are copies of some of
the most useful info from key sites---the websites themselves maybe overwhelmed with traffic and access
can become impossible.
 Information and links to any policies that have changed because a pandemic has been declared
 Suggested ways to set up babysitting pools
 Info on how to enter the medical center to be ‘cleared” to work
Ongoing communication with in-house associates and other medical or hospital-related personnel 
The Intranet has been established as the primary means for updating in-house medical center staff and affiliated
physicians, etc. on an ongoing basis so they will be current at to what’s going on in-house and squelch rumors.
 The intranet “ticker” (scrolling message) will direct associates and others to appropriate information areas
on the intranet or list the overall status of the hospital.
 There will be web pages for updated info on such things as departments, wings, floors considered under
isolation.
 Information on the next transport shuttle picking up/dropping off staff as well as locations & maps---and
an area for at-home staff to sign-up for the shuttle routes,
 Links to helpful websites such as CDC, health department, etc. AND pages on our site that are copies of
some of the most useful info from key sites---the websites themselves maybe overwhelmed with traffic and
access can become impossible.
(In addition to the website, we need an 800-number service for associates without internet access, where we can
update a recorded message for staff regarding the event and answer questions regarding reporting for duty, etc.
We may use TLC and/or CARE for this. Volunteers with previous healthcare experience should also be considered
for staffing this area.)
Pandemic
Door signs –
Management Team communication meetings
7. Infection Control
Designation of appropriate precautions is based on CDC recommendations and will continue to be updated if
changes occur in the anticipated pattern of transmission (www.cdc.gov/flu).
The following categories of Infection Control are considered in this plan:
1. Standard Precautions
2. Isolation Precautions
3. Visitors
4. Cleaning, Disinfection and Sterilization
5. Environmental Cleaning
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Standard Precautions
Although droplet and contact precautions are recommended in preventing the transmission of influenza during an
interpandemic period, these precautions will not be achievable during a pandemic. In contrast, adherence to
routine practices is achievable during a pandemic. Standard Practices are summarized below:
1) Hand hygiene, 2) Hygienic measures, 3) Personal Protective Equipment (ppe),
1. Hand Hygiene
Staff, patients and visitors should recognize that strict adherence to hand hygiene recommendations is
the cornerstone of infection prevention and may be the only preventative measure available during a
pandemic.
 Hand hygiene procedures should be reinforced with all staff, patients and visitors.
 Hands should be washed or hand antisepsis performed after direct contact with patients/workers with ILI and
after contact with their personal articles or their immediate environment.
2. Hygiene Measures to Minimize Influenza Transmission
Patients, staff and visitors should be encouraged to minimize potential influenza transmission through good
hygienic measures:
 hand hygiene after coughing, sneezing or using tissues;
 use of disposable, one-use tissues for wiping noses; covering nose and mouth when sneezing and coughing;
 keeping hands away from the mucous membranes of the eyes and nose.
3. Personal Protective Attire
During the early phase of an influenza pandemic (when immunization and antivirals are not yet available) –
healthcare providers should wear masks when interacting in close face-to-face contact with coughing individuals to
minimize influenza transmission.
Masks



Masks should be worn to prevent the transmission of other organisms when HCWs are face-to-face with
undiagnosed cough patients.
HCWs should avoid touching their eyes with their hands to prevent self-contamination with pathogens.
National Institute for Occupational Safety and Health (NIOSH)-certified respirators (N-95 or higher) are
recommended for use during activities that have a high likelihood of generating infectious respiratory
aerosols (If protection from splashes of blood or body fluids is also needed, NIOSH-certified, FDA-cleared
surgical N-95 (or higher) respirators should be selected) including the following high-risk situations:
 Aerosol-generating procedures (e.g., endotracheal intubation, nebulizer treatment, and
bronchoscopy) performed on patients with confirmed or suspected pandemic influenza
 Resuscitation of a patient with confirmed or suspected pandemic influenza (i.e., emergency
intubation or cardiac pulmonary resuscitation)
 Providing direct care for patients with confirmed or suspected pandemic influenza-associated
pneumonia (as determined on the basis of clinical diagnosis or chest x-ray), who might produce
larger-than-normal amounts of respirable infectious particles when they cough
In the event of actual or anticipated shortages of N-95 respirators:

Other NIOSH-certified N-, R-, or P-class respirators should be considered in lieu of the N-95
respirator.

If re-useable elastomeric respirators are used, these respirators must be decontaminated according
to the manufacturer’s instructions after each use.

Powered air purifying respirators (PAPRs) may be considered for certain workers and tasks (e.g.,
high-risk activities). Loose-fitting PAPRs have the advantages of providing eye protection, being
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
comfortable to wear, and not requiring fit-testing; however, hearing (e.g., for auscultation) is
impaired, limiting their utility for clinical care. Training is required to ensure proper use and care of
PAPRs.
Efforts will be made by Incident Command to ensure that excess respirators are not held in reserve while
health care personnel are conducting activities for which they would otherwise be provided respiratory
protection. Conversely, excessive use of respirators could result in their unavailability for high-risk
procedures. Note: Decision guidance for determining respirator wear should consider factors such as
duration, frequency, proximity, and degree of contact with the patient.
If supplies of N-95 (or higher) respirators are not available, surgical masks can provide benefits against
large droplet exposure, and should be worn for all health care activities for patients with confirmed or
suspected pandemic-influenza.
Gloves

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

Gloves are not required for the routine care of patients suspected or confirmed to have influenza.
Meticulous hand hygiene will inactivate the virus.
Gloves should be worn to provide an additional protective barrier between the HCWs hands and blood,
body fluids, secretions, excretions and mucous membranes to reduce the potential transfer of
microorganisms from infected patients to HCWs and from patient-to patient via HCWs’ hands.
Gloves are necessary for HCWs with open lesions on their hands when providing direct patient care.
Gloves should be used as an additional measure, not as a substitute for hand Hygiene.
Gloves should not be reused or washed.
Gowns




Gowns are not required for the routine care of patients suspected of confirmed to have influenza.
Long sleeved gowns should only be used to protect uncovered skin and to prevent soiling of clothing
during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids,
secretions or excretions.
HCWs should ensure any open skin areas/lesions on forearms or exposed skin is covered with a dry
dressing at all times. Intact skin that has been contaminated with blood, body fluids, secretions or
excretions should be
washed as soon as possible, thoroughly, but gently with soap and warm running water.
Isolation / Separation
Alert Period
1. Engineering and/or administrative controls, including Isolation precautions and Personal Protective Equipment
(PPE), are used to prevent or control transmission of infections.
a. measures can be employed to minimize the number of personnel required to come in contact with
suspected or confirmed pandemic influenza patients, thereby reducing worker exposure and minimizing
the demand for respirators. Such measures include the following:
 Establishing specific cohort locations for patients with pandemic influenza
 Assigning dedicated staff (e.g., health care, housekeeping, janitorial) to provide care for
pandemic influenza patients and restricting those staff from working with non-influenza
patients
 Dedicating entrances and passageways for influenza patients.

2. ?? include??The SERMC Respiratory Protection program (See Safety Manual) includes
 appropriate fit-testing.
 Designation of associates who may be required to wear respiratory protection.
 Medical clearance requirements
 Suitable respirator model
 Training in respirator use.
Isolation Precautions
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Droplet Precautions
known or suspected pandemic influenza
Airborne Precautions
Contact Precautions
immunocompromised patients
Cough-inducing procedures
If the pandemic virus is associated with diarrhea
At least 5 days from the onset of
symptoms
Duration of illness
Duration of illness
Pandemic Period
Segregation
1. Visual alerts are posted at the entrances to hospital and outpatient facilities in languages appropriate to the
population served, with instructions to:


Immediately report symptoms of respiratory infection to the healthcare provider.
Wash hands with soap and water or alcohol-based hand gel after contact with respiratory secretions.
2. Infected and uninfected persons (patients, visitors and staff) are separated as early as possible
 open cohort areas/units in the hospital (See appendix…)
 Limit movement/activities of patients including transfers within the hospital, unless the patient has recovered
from pandemic influenza.
 In common waiting areas, maintain spatial separation (ideally at least 3 feet) between symptomatic person and
others. Including the following waiting areas:
o Patient Registration
o Emergency Department
o …
 Patients with ILI who are coughing should only leave their room for urgent/necessary procedures, and should
wear a surgical mask whenever they need to be out of their room until the period of communicability of the
pandemic strain has passed.
 Triage outpatients according to the presence or absence of influenza symptoms to identify patients who need
emergency care and those who can be referred to a medical office or other non-urgent care facility. (See ???)
 Implement “Access Screening and Control” to triage symptomatic persons.
o Use Clinical Triage Guidelines (see Section 10)
o Initiate Access Control
o Establish a “triage officer” to manage flow, including deferring or redirecting patients who do not
require emergency care, after performing a medical screening examination.
o Consider designating a separate entrance and waiting area for patients with influenza-like symptoms.
Source Control Measures
 covering mouth/nose with a tissue when coughing
 disposing of used tissue in contained receptacles
 applying a surgical or procedure mask on the coughing person, as tolerated.
3. Negative Pressure Rooms
Negative pressure isolation is not required for routine patient care of individuals with pandemic influenza.

If possible, airborne infection isolation rooms should be used when performing high-risk aerosolgenerating procedures. If negative pressure isolation rooms are NOT available, these activities in a
private room (with the door closed) or other enclosed area, if possible, and to limit personnel in
the room to the minimum number necessary to perform the procedure properly.
4. Social Distancing
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Saint Elizabeth has the ability to utilize the following social distancing strategies to reduce close contact among
individuals:
Telecommuting. The number of associates who have the technological capacity to telecommute from home and
can adequately perform their primary functions from home is: ___________. See list in Appendix ??
Teleconferences. Teleconferences can be held within the following units:
Staggering work shifts. The number of people who do not need to perform their work during the same time of
the day and can be spread out in the 24 hours period are _____. The number of associates who can work an
extended number of days in fewer days are____________.
Face-to-face barriers. The number of associates who have regular face-to-face contact with the public should
be limited as much as possible. Services that can be reorganized to be provided to the public without face-to-face
contact are:
*Other infection control strategies can be used to reduce the spread of disease between associates who must have
face-to-face contact with others.
Visitors



There are no restrictions for asymptomatic visitors who have recovered from pandemic influenza or who have
been immunized against the pandemic strain of influenza.
Visitors with ILI should not visit until they are asymptomatic. Close relatives of terminally ill patients can be
exempt, but should put a mask on upon entry into the facility and their visit shall be restricted to that patient
only.
Visitors should be informed when the acute care facility has influenza activity. Those who have not yet had the
pandemic strain of influenza or who have not been immunized against the pandemic strain should be
discouraged from visiting. Close relatives of terminally ill patients can be exempt, but they should restrict their
visit to that individual only and they should wash their hands on exit from the patient’s room. Wearing a mask
upon entry to the facility is only useful if there is no influenza in the community.
Cleaning, Disinfection, and Sterilization of Patient Care Equipment


Acute care settings should adhere to the recommendations for cleaning, disinfection and sterilization of patient
care equipment.
Follow standard facility procedures for care of the deceased. Practices should include standard precautions for
contact with blood and body fluids.
Environmental Control (Housekeeping, Laundry, Waste)
Acute care settings should adhere to the recommendations for housekeeping, laundry and waste management.
 Equipment and surfaces contaminated with secretions from patients suspected or confirmed to have influenza
should be cleaned before use with another patient.
 Special handling of linen or waste contaminated with secretions from patients suspected or confirmed to have
influenza is not required.
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Education / Training
1. Educational information for workers will be provided as soon as WHO Pandemic Phase 3 is declared and
repeated at frequent intervals to all staff levels and during all shifts.
2. The pandemic influenza information should be appropriate to the audience and be provided using a variety of
methods, e.g., postings in elevators, at facility entrances, brochures, newsletters and web sites.
3. Education and training materials are available to educate staff at the appropriate level about Pandemic
Influenza and the Medical Center’s plan for response (See Appendix ??) including provisions for
 Language and reading level-appropriate materials Current and potential sites for long-distance and local
education of clinicians on pandemic influenza have been identified.
 Means for accessing state and federal web-based influenza training programs have been identified.
 A system for tracking which personnel have completed pandemic influenza training is in place.
4. The following groups of healthcare personnel have received training on the facility’s influenza plan:
 Physicians
 Nursing staff
 Laboratory staff
 Emergency Department
 Outpatient personnel
 Environmental Services
 Engineering and maintenance
 Security personnel
 Nutrition personnel
5. The educational information prepared and provided for workers should include:
a. An explanation that pandemic influenza is a novel strain of influenza and what a pandemic is;
b. The facility-specific pandemic influenza plan;
c. The difference between an upper respiratory infection and influenza
d. The mode of influenza transmission
e. The criteria for determining, influenza-like-illness (ILI)
f. The risk of infection and subsequent complications in high-risk groups;
g. The message that strict adherence to hand hygiene recommendations is the cornerstone of
infection prevention and may be the only preventative measure available during early phases
of the pandemic
h. Information about the importance of hygienic measures to minimize influenza transmission because
influenza immunization and/or prophylaxis may not be available until later in the pandemic;
i. Information indicating that, during the early phase of an influenza pandemic, it maybe feasible for HCWs to
wear masks when face-to-face with coughing individuals to minimize influenza transmission (particularly
when immunization and antivirals are not yet available) but not practical or helpful when transmission has
entered the community. Masks should be worn by HCWs to prevent transmission of other organisms from
patients with undiagnosed cough;
j. recommendations for Occupational Health Management of workers during a pandemic;
k. Who will be given the highest priority for immunization when vaccine is available;
l. The importance of being immunized and safety of immunization;
m. Who will be given what priority for prophylaxis when antivirals are available, the importance of prophylaxis
and safety of prophylaxis
n. Information about the importance of routine practices and additional precautions to prevent the
transmission of infection during the delivery of health care in all health care settings during a pandemic.
(This information should include the caveat that some routine practice and additional precaution
recommendations may be achievable only in the early phases of the pandemic and other recommendations
may not be achievable as the pandemic spreads and resources (equipment, supplies and workers) become
scarce.
6. The educational information prepared and provided for Management Team should include:
a. Influenza basics:
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 Explanation that pandemic influenza is a novel strain of influenza and what a pandemic is
 The criteria for determining, influenza-like-illness (ILI)
 The risk of infection and subsequent complications in high-risk groups;
b. Decision-Makers and Authorities
c. How is Seasonal Flu Transmitted?
d. Pandemic Flu and Your Job
e. Infection Control and Patient Care
f. Influenza Preparedness Plan
7. Priority for infection control resources (including cleaning) should be assigned to acute care settings because of
the complexity of managing high risk patients in acute care settings.
8. A plan is in place for rapidly training non-facility staff brought in to provide patient care when the hospital
reaches surge capacity, including temporary and volunteer staff
9. Triage and Admission
 Early Pandemic Phase 6: Triage of patients with possible pandemic influenza will occur:
_____________________________________ until _____________________________________; then
________________________________________
 Signs are used in the ambulance bay and ?? to direct and instruct patients with possible pandemic influenza on
the triage process.
 Supplies for Cough Etiquette and personal protective equipment are available for staff, patients and visitors
 Patients with possible pandemic influenza will be physically separated from other patients seeking medical
attention by assigning them to ___________________________
 The system described in Appendix ?? (including criteria) is used for phone triage of patients for purposes of
prioritizing patients who require a medical evaluation has been developed using TLC
 A method for tracking the admission and discharge of patients with pandemic influenza has been developed.
(use Meditech)
 Patients may be screened on admission for recent seasonal influenza vaccination and pneumococcal
vaccination. Those without a history of immunization should receive these vaccines before discharge, if
indicated.
 Maintain awareness of seasonal influenza and other ILI disease patients that may be encountered intermixed
with pandemic influenza patients. (See Appendix 11: Clinical Presentation and Complications of
Seasonal Influenza and Appendix 12: Comparison of Flu, Colds, and Pertussis)
 When triage criteria change, Emergency Department staff is informed via….
10. Clinical Guidelines
Case Detection and Clinical Management of Influenza-like illness
Alert Period
(Phase 4: Small cluster(s) with limited human-to-human spread is highly localized, suggesting; that the virus is not well adapted to humans;
Phase 5: Larger cluster(s) but human-to-human spread is still localized, suggesting that the virus is becoming increasingly better adapted to
humans but may not yet be fully transmissible (substantial pandemic risk).





Tissue, alcohol cleanser and cough kit are available in the Triage area and waiting room.
At triage point - Patients screened for Influenza-Like Illness (ILI)
a. Fever >100.4
b. Any of these three: Cough, Dyspnea, Sore throat
c. If positive for “a” and any of “b”, ask travel questions.
Give the patient a mask and escort to ED isolation rooms (8, 9, 10). * If more rooms are needed, use a
separate waiting room area.
Notify the Infection Control Coordinator and House Supervisor of possible infection
Determine need for hospitalization
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If admission is needed, admit to Med/Onc, PCU, CCU or Peds (Providers possibly involved in admission: IMS,
Intensivists, ID, Patient’s personal physician)
If admission is NOT needed, utilize discharge planning via Social Services, Case Managers, or Home Health.
Teach patient home care infection control.
*supplies needed: gloves, masks, gowns, alcohol cleanser
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Pandemic Period
(Pandemic phase: increased and sustained transmission in the general population).


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



Tissue, alcohol cleanser and cough kit are available in the Triage area and waiting room.
At triage point - Patients screened for Influenza-Like Illness (ILI)
a. Fever >100.4
b. Any of these three: Cough, Dyspnea, Sore throat
c. If positive for “a” and any of “b”, ask travel questions.
Give the patient a mask and escort to ED isolation rooms (8, 9, 10). * If more rooms are needed, use a
separate waiting room area.
Notify the Infection Control Coordinator and House Supervisor of possible infection
Determine need for hospitalization
If admission is needed, admit to Med/Onc, PCU, CCU or Peds (Providers possibly involved in admission: IMS,
Intensivists, ID, Patient’s personal physician)
If admission is NOT needed, utilize discharge planning via Social Services, Case Managers, or Home Health.
Teach patient home care per printed Home Care Pandemic Guidelines.
*supplies needed: gloves, masks, gowns, alcohol cleanser
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Assessment: (link to Meditech screen here)
In addition to the clinical assessments appropriate to the patient’s care, assess all patients with symptoms of ILI
illness for
1) Recent travel
2) Recent exposure to animals
3) Recent exposure to persons with infectious disease
Travel risks:
Persons have a travel risk if they have:
1. Recently (within 10 days prior to onset of illness) visited or lived in an area affected by highly pathogenic
avian influenza A outbreaks in domestic poultry or where a human case of novel influenza has been
confirmed, and either
2. Had direct contact with birds or poultry, Direct contact with poultry is defined as: 1) touching birds (wellappearing, sick or dead), or 2) touching poultry feces or surfaces contaminated with feces, or 3)
consuming uncooked poultry products (including blood) in an affected area
Or
3. Had close contact with a person with confirmed or suspected of having a flu-like illness. Close contact with
a person from an infected area with confirmed or suspected a flu-like illness is defined as being within 3
feet of that person during their illness.
Exposure to animals:
Inquire about :
1. contact (within 3 feet) of any live poultry OR domesticated birds (e.g., visited a poultry farm, a household
raising poultry, or a bird market?
2. direct contact with any recently butchered poultry?
Occupational risks:
Persons at occupational risk for infection with a novel strain of influenza include persons whom:
1.
2.
3.
4.
5.
work on farms
work with live poultry markets
who process or handle poultry infected with known suspected avian influenza viruses,
work in laboratories that contain live animal or novel influenza viruses,
work as healthcare workers in direct contact with a suspected or confirmed novel influenza case.
Infection Prevention in ED
1. Standard and Droplet Precautions should be used when caring for patients with novel influenza OR
seasonal influenza.
Hospitalization
1. The decision about hospitalization of patients with known or suspected influenza should be based on all
clinical factors, including
a. the potential for infectiousness and the ability to practice adequate infection control.
b. If hospitalization is not clinically warranted, and treatment and infection control is feasible in the
home, the patient may be managed as an outpatient. The patient and his or her household should
be provided with information on infection control procedures to follow at home. The patient and
close contacts should be monitored for illness by local public health department staff.
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2. During a pandemic, the decision to hospitalize should be based on a clinical assessment of the patient and
the availability of hospital beds and personnel.
3. If being discharged to Home, provide with standardized instructions on home management of fever and
dehydration, pain relief, and recognition of deterioration in status. Patients should also receive information
on infection control measures to follow at home. (see attachment)
Standing Orders:
1. Diagnostic Tests: Depending on the clinical presentation and the patient’s underlying health status, initial
diagnostic testing might include: (order set link)
a. Pulse oximetry
b. Chest X-ray
c. Laboratory Tests
i. Complete blood count (CBC) with differential
ii. Blood cultures
iii. Sputum (in adults), tracheal aspirate, pleural effusion aspirate (if pleural effusion is
present): Gram stain, culture and sensitivity
iv. Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or
1. swabs for common viral respiratory pathogens, such as influenza A and B,
adenovirus,
2. Children: PCR of parainfluenza viruses, and respiratory syncytial virus
3. Adults with radiographic evidence of pneumonia: Legionella and pneumococcal
urinary antigen testing
v. adults and children <5 yrs with radiographic pneumonia: PCR for M. pneumoniae and
Chlamydia Pneumoniae
vi. Comprehensive serum chemistry panel, if metabolic derangement or other end-organ
involvement, such as liver or renal failure, is suspected
vii. All of the following respiratory specimens should be collected for novel influenza A virus
testing: nasopharyngeal swab; nasal swab, wash, or aspirate; throat swab; and tracheal
aspirate (for intubated patients), stored at 4°C in viral transport media; and acute and
convalescent serum samples.
2. Admission Orders (order set link)
a. Standard Precautions + Droplet Precautions.
b. IV solution:____________________________
c. Vital signs: ____________________________
d. O2: __________________________________
e. Activity: ________________________________
f. Diet: __________________________________
g. Medications:
 Antivirals
 Antibiotic
 Home Meds
 Antipyretic
Treatment
1. Given the unknown sensitivity of tests for novel influenza viruses, interpretation of negative results should
be tailored to the individual patient in consultation with the local health department. Novel influenza
directed management might need to be continued, depending on the strength of clinical and epidemiologic
suspicion. Antiviral therapy and isolation precautions for novel influenza may be discontinued on the basis
of an alternative diagnosis. The following criteria may be considered for this evaluation:

Absence of strong epidemiologic link to known cases of novel influenza
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
Alternative diagnosis confirmed using a test with a high positive-predictive value

Clinical manifestations explained by the alternative diagnosis
2. Antiviral therapy and isolation precautions for pandemic influenza should be discontinued on the basis of
an alternative diagnosis only when both the following criteria are met:

Alternative diagnosis confirmed using a test with a high positive-predictive value, and

Clinical manifestations entirely explained by the alternative diagnosis.
11. Use and Administration of Vaccines and Antiviral Drugs
Vaccine
Influenza vaccine availability in the early phase(s) of the pandemic is uncertain. When available, vaccine will be
provided according to priority groups set by recommendations from the CDC and Nebraska Department of Health
and Human Services.
SERMC has assigned priority for use of vaccines and antivirals among associates in a pandemic when in short
supply includes:
First priority personnel
Number
Second priority personnel
Remaining priority personnel
Anti-Viral Agents
The State of Nebraska has planned to make the following available to Saint Elizabeth Regional Medical Center from
their portion of the National Stockpile. Saint Elizabeth will use all doses provided as treatment doses.
 50 prophylactic courses
 3157 treatment courses
Antiviral availability in the early phase(s) of the pandemic is uncertain. When available, antivirals will be provided
according to priority groups set by recommendations from the state. At this time, health care workers and those
trainees, volunteers, etc. who are recruited to perform the duties of a HCW are considered to be a high priority.
Relative priorities regarding target groups and the use of limited supplies for chemoprophylaxis versus therapy
have not yet been established. However, WHO recommends the use of antivirals for treatment only. In general,
priority groups for receipt of antiviral agents should be consistent with priorities for vaccine administration.
SERMC has assigned priority for use of vaccines and antivirals among patients in a pandemic when in short supply
includes:
First priority personnel
Number
Second priority personnel
Remaining priority personnel
The system for rapidly distributing vaccine and antivirals to patients has been developed. (See appendix ??)
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12. Surge Capacity
To respond to a significant increase in the number and acuity of patients requiring inpatient and outpatient care,
modifications are needed for 1) staff, 2) space, 3) supplies and equipment.
To maximize healthcare resources and achieve the optimal benefit for the most people, traditional standards of
care may need to be altered. “Sufficiency of care,” medical care that may not be of the same quality as that
delivered under non-emergency conditions but that is sufficient for need, may be the standard of care during an
influenza pandemic.
Difficult decisions may be required at times, when patient needs exceed the ability to provide the care and/or
services needed, e.g., ventilator support, critical care, etc. The Ethics Committee will be utilized for assistance in
making these decisions.
1. Staffing
Critical staff roles have been identified to include the following:




Direct Care providers (expand)
Housekeepers
Food Service
Linen Services




Plant operations
Security officers
Chaplains
Add others
Develop streamlined nursing notes/patient care records – Don’t know where to put this??
2. Space
According to the Medical Center’s Capacity Management Plan (Administrative Manual) management of situations in
which a bed shortage exists are coordinated by the House Supervisor and unit Directors via periodic census
meetings. Collaboration with the Incident Command should also occur during a designated emergency such as a
Pandemic.
Providing for space needs is accomplished in three ways during the phases listed below:
1) Expanding current beds
Use of non-traditional patient care locations should be considered, according to
the following Tables I and II.
2) Postponing Elective utilization (Surgeries, Admissions, Procedures)
Elective admissions may be cancelled or postponed at the direction of the
Incident Commander for the purpose of freeing beds, space, staff and
equipment and/or preventing exposures.
Existing Operating Room procedures for notification of patients, surgeons, and
staff about cancellation of procedures are followed.
3) Rapid Discharge of Patients
When the need for additional beds arises, the Rapid Discharge / Transfer of
patients protocol should be utilized (EC4.13, Appendix G)
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Resource allocation
When ventilator equipment and staff resources are limited, patients are assigned to ventilators and ventilator units
based on a triage algorithm capturing the findings of an initial assessment of acuity of illness combined with the
prognosis for survival. See Appendix ??, Appendix ???, Appendix ????, and Appendix ?????.
3. Supplies and Equipment
The following pharmaceuticals and durable and consumable supplies are anticipated to be in short supply
National Stockpile supplies are accessed through the State of Nebraska, Department of Health and Human
Services.
Pharmaceuticals

Vaccine

Antibiotics

IV fluids
Consumable Resources





Hand hygiene supplies (antimicrobial soap
and alcohol-based, waterless hand hygiene
products)
Disposable N95, surgical and procedure
masks
PAPR tubing and other disposable materials
Isolation masks for patients
Gowns






Gloves
Facial tissues
Central line/PICC kits (for administration of
antibiotics)
Body bags or alternatives
Eye protection
Tubing for the ventilators ..
Durable Resources
a. Ventilators
 Impact Ventilators are utilized due to the reduced level of expertise required for management of the
patient. Similar ventilators are used at other CHI hospitals, including Good Samaritan Hospital,
Kearney.
 The typical (normal situation) staffing package for a ventilator unit of 24 patients includes:
1. 12 Critical Care trained RN
2. 5 Respiratory Therapists
3. 5 CNAs or students
 An alternative (emergency situation) staffing package for a ventilator unit of 24 patients is:
1. 6 Critical Care trained RN
2. 6 General Care RN
3. 2 Respiratory Therapists
4. 2 CNAs or students
 Training for ventilator management is provided prior to expectations of providing care. Ventilators are
used whenever possible prior to the pandemic to ensure maximum familiarity and competence with the
ventilator.
Consumable Resources
4. Rationing of Care
Role of Ethics Committee when insufficient resources are available to provide for patients.
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13. Designate a Morgue area
Excess mortalities will occur which may exceed the ability of the mortuary community to respond to. Therefore, it
may be necessary to establish alternative holding areas for bodies of deceased.
1. Bodies of deceased may be held for up to 24 hours without refrigeration
2. Chain of custody procedures may be required, as directed by Security.
3. On-site:
a. Distribution storage area
b. Bed storage area
c. Cardiac Rehab
d. Decontamination tent
4. Off-site
a. VA Medical Center
14. Security / Facility Access
Criteria and protocols for closing the facility to new admissions are in place.
Criteria and protocols for limiting visitors have been established.
Hospital Security has had input into procedures for enforcing facility access controls.
Limit the number of entrances to the healthcare facility, based on ability to provide appropriate screening.
Provide security at entrances.
15. Human Resource Issues
a. Staffing
Work force preservation protocols have been established to minimize absenteeism, which may include:
 Establishing a staff hotline with current information
 Providing sick-care services for children of hospital staff
 Developing rosters of staff teams to allow for rotation and rest over the duration of the pandemic.
 Develop and conduct staff training on the facility’s pandemic response plan.
 Prepare to manage volunteer personnel, including:
o Granting emergency privileges
o Establishing competency and monitoring staff performance for newly recruited and/or volunteer
personnel
o Assigning temporary personnel
o Using retired and volunteer healthcare workers for some patient care roles
o Using community volunteers for non-clinical roles such as transporting specimens, registration and
supply handling
o Training volunteers
b. Management of Human Resources
Some Human Resources Policies may require modification or implementation during a Pandemic. These policies
have been developed in advance of implementation.
Policies requiring / not requiring modification are addressed in a Personnel Policy entitled: “Human Resource
Management during Emergency Management Plan Implementation”, including the following:
Policy
#
100
Policy Name
Emergency Need Addressed
Attendance
Increased absence due to illness in family or community
Reporting Late or Leaving early
24
1000
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
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Revision #16
Last Revision date 7/30/07
Recording Time Worked – work-at-home policies
Work Schedule – Unusual staffing pattern requiring a revision
of the posted schedule
Discipline related to absences for illness / family illness
Not completing shift (unrelated to illness)
Termination
Defines:
 Associate-initiated terminations
 Employer-initiated terminations
 Disability
Reinstatement of Prior Service
120
225
Snow and/or Emergency Weather
Conditions
Employment
Licensure
Background Checks
Pre-placement Post-offer Health
Screen
Staff Competence
Performance Based Development
System
Employment with Contracting
Agencies
Flex Staffing
230
Associate Orientation
240
Staff Rights in the Refusal to Provide
Treatment
Employees working for contract agencies caring for patients at
SERMC
Flex staff is required to accept increased hours from 56 to
80/pp
Orientation of new associates / temporary associates during
emergency circumstances.
Address the potential refusal of staff to provide care for
infectious patients or patients in a different care area.
Employment Status
Failure to comply may result in disciplinary action up to and
including termination.
Rapid-hire process during an emergency
200
202
203
210
220
221
222
270
Emergency Credentialing procedures
Emergency Credentialing procedures
Rapid-hire process during emergency situations
Temporary staff
Retired / volunteer staff
280
285
Required Time Off (RTO)
Reduced Activity
312
Short Staffing Payment Program
Medical Center closure
Premium Pay is needed as an incentive to recruit current staff
to work additional hours
325
326
327
Hazard pay?
335
On Call and Call Back Policy
Extended Shift Call policy
Compensating Exempt Staff in Critical
Staffing Shortages
Overtime
410
Workers’ Compensation
Department activity has ceased due to emergency
circumstances. Associate is not needed during this time.
Requiring overtime when no relief is available for direct-care
providers
Limiting the duration of overtime to be safety worked
25
420
430
440
445
455
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Personal Leave
Cancellation of leave and vacations
Short-term Disability
Family and Medical Leave
Family member illness
Leave of Absence without Pay
Bereavement Leave
Time required for grieving the death of family members
1136
Internet Usage Policy
Addresses use of Internet while on-duty
The following policies are not covered by existing Personnel Policy. Policies developed for the following conditions
are implemented during emergency situations by Incident Command decision:
 Knowingly coming to work ill
 School closure
 Social distancing of non-essential personnel / Work at home
 Organization-imposed quarantine
 Work assignments for healthcare workers at high risk for complications of flu
c. Occupational Health
The phrases “fit for work,” “unfit for work” and “fit to work with restrictions” are used to communicate a worker’s
ability to remain at or return to work depending upon their susceptibility to influenza, immunization status and
agreement to use antiviral.
During Pandemic Alert and Pandemic phases, infected individuals will be asked to remain home.
1. Notify associates via the website and departmental communication they should not come to work if they are
unwell, particularly if they are exhibiting any influenza symptoms (See Appendix ??, ILI Assessment Tool)
2. Post notices at all entry points advising staff and visitors not to enter if they have influenza symptoms.
3. Advise associates to call Employee Health (7044) if they become ill at home or work.
4. Employee Health has been provided with a protocol for associates who become ill. (See Appendix ??, Protocol
for Associates who Become Ill.)
5. Ensure that ill employees have completed the required isolation period (guidance to be provided by the
Lincoln-Lancaster County Health Department and are healthy and no longer infectious before allowing them to
return to work. Note that staff who have recovered from the pandemic influenza are less likely to be reinfected and should be encouraged to return to work.
1. Fit for Work
a. Ideally, HCWs are fit to work when one of the following conditions apply:
i)
They have recovered from ILI illness during earlier phases of the pandemic;
ii)
They have been immunized against the pandemic strain of influenza
iii)
They are on appropriate antivirals.
b. Such HCWs 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.
c. Whenever possible, well, unexposed HCWs should work in non-influenza areas.
d. Asymptomatic HCWs may work even if influenza vaccine and antivirals are unavailable. Meticulous attention
should be paid to hand hygiene and HCWs should avoid touching mucous membranes of the eye and mouth 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; nonetheless, due to limited
resources, these HCWs may be asked to work if they are well enough to do so (see 3 (b) below).
3. Fit to Work with Restrictions
a. Ideally, symptomatic staffs who are considered “fit to work with restrictions” should only work with patients
with ILI. Health Care Workers who must work with non-exposed patients (noninfluenza areas) should be
required to wear a mask if they are coughing and must pay meticulous attention to hand hygiene.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
b. Symptomatic HCWs who are well enough to work should not be redeployed to intensive care areas, nurseries
or units with severely immunocompromised patients, i.e., transplant recipients, hematology/oncology patients,
patients with chronic heart or lung disease, or patients with HIV/AIDS and dialysis patients.
16. Recovery of Operations
Finance – all of the following will be available over the web by 10/07 with CHI Connect:
 Invoices are scanned
 Account payable are scanned
 Payroll scanned
Per Mike, Finance could operate from anywhere, so long as the data is available from the source (CHI central
storage)
Inventory – in Meditech. Believe this is backed up with NITC in Denver. Do they back up off-site somewhere else?
Human Resource Files – Backed up with NITC in Denver. Do they back up off-site somewhere else?
17. Contacts
Authority and responsibility for aspects of the pandemic plan and response within the facility







Surveillance – reviewing global, national, regional, and local influenza activity trends - Lori Snyder-Sloan
Updating public health reporting – Infection Control Coordinator (Lori Snyder-Sloan or Irene Kemper)
Media spokesperson for the facility – Public Information Officer (Jo Miller or Donell Martinez)
Clinical spokesperson for the facility – assigned by the Media Spokesperson
Responsible for providing updates to public information sitesResponsible for providing updates to associate information sitesAdd here…
Key Contacts – SERMC and Community
Saint Elizabeth
Influenza preparedness coordinator – Lori Snyder-Sloan
Members of the planning committee include the following hospital staff members
 Administration – Barb George
 Infection control /Hospital disaster coordinator Lori Snyder-Sloan
 Facility engineering – Bob Potter (Surge Capacity subcommittee)
 Nursing administration / Intensive care - Barb George
 Medical staff - Denise Capek
 Emergency Department – Cathy Rasmussen, Denise Capek
 Laboratory services – Donnet Knapp
 Respiratory therapy – Jay Snyder (Surge Capacity subcommittee)
 Environmental services – Pam Livingston (Surge Capacity subcommittee)
 Public relations – Jo Miller
 Security – Steve Imes
 Materials management – Marty Liebentritt & Cathie McBride-Hilzer
 Staff development - ??
 Occupational health – Jaime Brewer
 Pharmacy – Richard Ternes
 Information technology – Kim Springer
 Food and Nutrition Services – Jan Wadell
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Community
 State
Nebraska Bioterrorism Epidemiologist (NHHS) 402-471-2937 or 402-471-1983
Nebraska Regional Poison Center 800-222-1222
Nebraska State Patrol 800-525-5555
 Local health department contact - Mark Hosking / Steve Beal - 441-6204____________________
 Emergency Manager – Doug Ahlberg 441-7441
 Newspaper contact(s) ________________________________________________
 Radio contact(s) ________________________________________________
 Public official(s) ________________________________________________
 Healthcare facilities with whom it will be necessary to maintain communication –
 BryanLGH East
 BryanLGH West
 Madonna Rehabilitation Hospital –
Pandemic Contact s
Saint
BryanLGH
BryanLGH
Madonna
Nebraska
LLCHD
Elizabeth
East
West
Heart
Hospital
Lori SnyderPandemic
Sloan
Coordinator
Infection
Control
Director of
Nursing
House
Supervisor
Public
Relations
(PIO)
Occupational
Health
Pharmacy
219-7333
Lori SnyderSloan
219-7333
Irene Kemper
219-7333
Kim Moore
219-7178
219-8990
Jo Miller
219-7061
Donell
Martinez
219-7445
Charlotte
Osborn-Holm
219-7044
Jaime Brewer
219-5054
Kurt Clyne
219-7044
Richard
Ternes
219-7049
Please add
your own
categories
you think will
be important
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? : Preparing for Selected Associates to Work From Home
Saint Elizabeth Regional Medical Center currently has the technology and systems for allowing associates
to work from home. This capacity is quite limited, providing the current connectivity is to be maintained
for Medical Center and SEPN users. (Approximately 20-30 additional associates could work from home
without adding additional licenses)
Background information:
1. The turnaround time for being able to acquire additional licenses is approximately 72 hours after the
request is made.
2. Use of the work-from-home access generally does not place extra demands on the hospital’s network
because the associate is working from their work computer’s desktop.
3. Access through the firewall is granted through a license. This commodity is NOT expected to be
influenced by other situations occurring in the world or the community.
4. A Citrix farm exists for ChartMaxx users. It is possible this could/should be expanded if the need for
ChartMaxx access from home is identified as a need in _____ associates.
Process:
1. Prior to the need arising, departments identify associates who could conduct their job responsibilities
from a site away from the hospital. Necessary systems and applications are also identified.
2. When the decision is made by the Incident Command to implement a Work From Home status:
a. Information Technology purchases additional licenses. (Currently 25 concurrent user
accesses cost approximately $2,000).
b. Instructions are provided to associates with job codes designated as “work from home”.
i. The associate browses to a website and logs in with the designated password.
ii. The remote-access client is downloaded onto the associate’s home computer. No
home visits are required at this point.
Associates able to Telecommute
Department
Job Code / Function
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? : Protocol for Employees who become ill
Advise employees that if a person feels ill, or if someone observes that another person is exhibiting
symptoms of influenza at work, they are to contact Employee Health by telephone if possible.
Employee Health will:
1. Speak with the individual by phone.
2. Check if the associate has any influenza symptoms. (See Appendix ?? ILI Assessment Tool)
 If the associate does not have any symptoms they are unlikely to have influenza and should be
reassured and advised to call again later or to see their doctor if they are still concerned.
 If the associate has influenza symptoms they should be treated as a “suspect influenza case.”
3. Complete a Suspect Influenza Case Form (Appendix …).
4. If the associate is at work provide them with a surgical mask and instruct them to put the mask
on immediately. (This is to help protect other staff.).
5. Instruct associate to leave work. If possible, public transportation should be avoided. If public
transportation is unavoidable, instruct the associate to keep the mask on and cough or sneeze
into a tissue while traveling.
6. Advise the associate to contact a health professional. This may involve phoning the person’s
normal doctor or a specially designated center to seek advice.
7. Advise the associate on how long to stay away from work (the Lincoln-Lancaster County Health
Department website, www.lincoln.ne.gov, will post isolation guidance).
8. Have the associate’s work station cleaned and disinfected
9. The Lincoln-Lancaster County Health Department may ask employers to
1) identify contacts (once an associate is suspected to be infected);
2) advise contacts that they have been in contact with a person suspected of having influenza;
and/or
3) ask contacts to go home, and stay home until advised otherwise.
10. The ill associate will contact their department per HR policy…
11. EHS will check on the associate during his/her absence from work and encourage associates to
return to work once they have recovered. (see below)
Criteria for Returning to Work
Workers who have become ill with influenza should stay at home until all of the following criteria are
met:
• At least 5 days have passed since the symptoms of illness began; AND
• Fever has resolved and has not been present for at least 24 hours; AND
• Cough is improving (decreasing in frequency and amount of secretions with no associated chest
discomfort or shortness of breath)
Upon returning to the work environment, employees should continue to follow cough etiquette and hand
washing protocols.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? Suspect Influenza Case Form -Management of Associates Who Become
Ill at Work
Details of affected associate
Name:
Date:
Date of Birth
Job Title:
Home Department:
Location of Isolation:
Address:
Telephone # _______________________________
Symptoms noted:








Fever (Temp > 100.4 ° F (fever)
Headache
Dry cough
_________________________________
Time of fever onset:__________
Time of isolation: ___________
Date expected to return to work: __________________
Cold
Sore throat
Body aches
Extreme Fatigue
Other: _____________________
**Symptoms and isolation periods will be updated by the LLCHD as information becomes available following the
emergence of a pandemic influenza strain.
Where referred:
Notes:
Details of reporter:
Name:
Job Title:
Telephone #:
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Special Populations
Several categories of special populations have been proposed and are defined below Although these categories
provide a basis for planning, it should not be assumed that every person within the broad category will require an
adapted response. Needs internal revision for appropriateness.
1. Physically disabled: Ranges from minor disabilities causing restriction of some motions of activities, to
totally disabled requiring full-time attendant care for feeding, toileting and personal care.
2. Mentally disabled: Ranges from minor disabilities where independence and ability to function inmost
circumstances is retained, to no ability to safely survive independently, attend to personal care, etc. This
also includes people whose mental illness makes them a danger to themselves or others.
3. Blind: Includes the range of visual challenges and impairments—low vision, night blindness, color
blindness, depth perception challenges, situational loss of sight, etc.
4. Deaf: Includes late-deafened, hearing impaired, hard-of-hearing and the range of hearing challenges and
impairments such as situational loss of hearing, limited range hearing, etc.
5. Medically dependent/fragile: Includes people dependent on life sustaining medications such as with
HIV/AIDS and diabetes, or dependent on medications to control conditions and maintain quality of life such
as pain or seizure control medications, etc.
6. Medically compromised: Includes people with multiple chemical sensitivities or weakened immune systems,
and those who cannot be in (or use) public accommodations for a variety of reasons.
7. Seniors: Includes frail elderly, aged, elder citizens, older persons and the range of people whose needs are
often determined by their age and age-related considerations.
8. Clients of the criminal justice system: Includes inmates, parolees, people under house arrest, registered
sex offenders, child molesters, etc.
9. Limited English or non-English speaking: Includes monolingual individuals as well as those with limited
ability to speak, read, write or fully understand English.
10. Homeless or shelter-dependent: Includes those marginally or temporarily housed or in shelters for abused
women and children.
11. Culturally isolated: Includes people with little or no interaction or involvement outside their immediate
community. This is the broad meaning of the words ‘culture’ and ‘community’, including religious, ethnic,
sexual orientation, etc.
12. Chemically dependent: Includes substance abusers and others who would experience withdrawal, sickness
or other symptoms due to lack of access, such as methadone users.
13. Children: Includes babies, infants, unattended minors, runaways and latchkey kids— anyone minor.
14. Single parents: Includes lone guardians, others with formal or informal childcare responsibilities—especially
those with no other support system.
15. Poor: Includes extremely low-income, without resources, without political voice, limited access to services
and limited ability to address their own needs.
16. Geographically isolated: No access to services or information, limited access to escape routes, or those for
whom geography overwhelmingly determines lifestyles, habits, behaviors or options.
17. Persons distrusting of authority: Includes people without documentation, political dissidents, and others
who will not avail themselves of government, American Red Cross or other traditional service providers for
a variety of reasons.
18. Animal owners: Includes owners of pets, companion animals or livestock— especially those who will make
life and death decisions based on animals, such as refusing to evacuate or go to a shelter if it means
separating from an animal.
19. Emergent special needs: Includes those developing special needs because of the disaster, such as
spontaneous anxiety/stress disorders, or recurrence of a dormant health condition, etc.
20. Transient special needs: Includes people temporarily classified as special needs due to a temporary
condition or status—such as tourists who will need care until they can leave, those who can’t see until
glasses are replaced, etc.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? An Influenza-like Illness (ILI) Assessment Tool
An ILI assessment tool is to be used for immediate triage of patients or staff and for
accommodation/cohort of patients prior to further OH or clinical management. This is not intended
to be used as a clinical management tool.
ILI in the general population is determined by the presence of 1, 2 and 3 and any of 4.,a–f,
which could be due to influenza virus:
Please check the following.
___ ( ) 1. Acute onset of respiratory illness
___ ( ) 2. Fever (>38 C)*
___ ( ) 3. Cough
___ ( ) 4. One or more of the following:
___ ( ) a. sore throat
___ ( ) b. arthralgia
___ ( ) c. myalgia or prostration
___ ( ) d. diarrhea**
___ ( ) e. vomiting**
___ ( ) f. abdominal pain*
* May not be present in elderly people
** May be present in children
Adapted from the ILI surveillance definition currently used by Flu Watch for the 2002-2003 season4.
33
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? : Infection Control Procedures
Component
Recommendations
Perform hand hygiene after touching blood, body fluids, secretions, excretions,
and contaminated items; after removing gloves; and between patient contacts.
Hand hygiene includes both handwashing with either plain or antimicrobial
soap and water or use of alcohol-based products (gels, rinses, foams) that
contain an emollient and do not require the use of water. If hands are visibly
Hand hygiene
soiled or contaminated with respiratory secretions, they should be washed with
soap (either non-antimicrobial or antimicrobial) and water. In the absence of
visible soiling of hands, approved alcohol-based products for hand disinfection
are preferred over antimicrobial or plain soap and water because of their
superior microbicidal activity, reduced drying of the skin, and convenience.
 For touching blood, body fluids, secretions, excretions, and
Personal protective equipment
contaminated items; for touching mucous membranes and nonintact
(PPE)
skin
 Gloves
 During procedures and patient-care activities when contact of
 Gown
clothing/exposed skin with blood/body fluids, secretions, and
 Face/eye protection (e.g.,
excretions is anticipated
surgical or procedure mask and
 During procedures and patient care activities likely to generate splash
goggles or a face shield)
or spray of blood, body fluids, secretions, excretions
Avoid touching eyes, nose, mouth, or exposed skin with contaminated hands
(gloved or ungloved); avoid touching surfaces with contaminated gloves and
Safe work practices
other PPE that are not directly related to patient care (e.g., door knobs, keys,
light switches).
Avoid unnecessary mouth-to-mouth contact; use mouthpiece, resuscitation
Patient resuscitation
bag, or other ventilation devices to prevent contact with mouth and oral
secretions.
Handle in a manner that prevents transfer of microorganisms to oneself,
Soiled patient care equipment
others, and environmental surfaces; wear gloves if visibly contaminated;
perform hand hygiene after handling equipment.
Handle in a manner that prevents transfer of microorganisms to oneself,
others, and to environmental surfaces; wear gloves (gown if necessary) when
handling and transporting soiled linen and laundry; and perform hand hygiene.
Soiled linen and laundry
Launder as per institutional guidelines for soiled linen (i.e., launder in hot water
70-80ºC (158-176ºF) if possible. Or laundry can be soaked in clean water with
bleaching powder 0.5% for 30 minutes. If this method is used, the laundry
should be washed again with detergent and water to remove the bleach.
Use devices with safety features when available; do not recap, bend, break or
Needles and other sharps
hand-manipulate used needles; if recapping is necessary, use a one-handed
scoop technique; place used sharps in a puncture-resistant container.
Use EPA-registered hospital detergent-disinfectant; follow standard facility
Environmental cleaning and
procedures for cleaning and disinfection of environmental surfaces; emphasize
disinfection
cleaning/disinfection of frequently touched surfaces (e.g., bed rails, phones,
lavatory surfaces).
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
 Unless otherwise instructed, all supplies and equipment should be
contained at the point of use and disinfected with the standard measures
Cleaning and Disinfection of
for cleaning, disinfection and sterilization.
equipment
 Standard cleaning/disinfection methods are used.
 Linen is handled using Standard Precautions.
Potentially infectious medical waste is managed according to Medical Center
policy.
Contain and dispose of solid waste (medical and non-medical) in accordance
with facility procedures and/or local or state regulations; wear gloves when
Disposal of solid waste
handling waste; wear gloves when handling waste containers; perform hand
hygiene.
Respiratory hygiene/cough
etiquette
Cover the mouth/nose when sneezing/coughing; use tissues and dispose in noSource control measures - implement
touch receptacles; perform hand hygiene after contact with respiratory
at first point of encounter (e.g.,
secretions; wear a mask (procedure or surgical) if tolerated; sit or stand as far
triage/reception areas) within a
away as possible (more than 3 feet) from persons who are not ill.
healthcare setting for persons with
symptoms of a respiratory infection;
Limit patient movement outside of room to medically necessary purposes; have
Patient transport
patient wear a procedure or surgical mask when outside the room.
Visitor Guidelines
Visitors have a responsibility to behave in a manner that does not put others at
risk, and to respond to staff's requests and hospital regulations for the
protection of themselves and others.
Guidance for the notification, surveillance and/or restriction of visitors is
dependent on the level of influenza activity in the world, national, state and
local levels:
Visitors(Visitor is defined as anyone
entering a healthcare facility site to visit a
patient or staff member, attend a meeting
or event, or accompanying an individual
accessing healthcare treatment,
assessment, examination or investigation).
Inter-pandemic
Signage:
Where visitors are allowed:
Precautions for visitors: (hand hygiene, masks, etc)
Training about precautions:
Screening:
Pandemic locally
Signage at entrances describing restrictions for all visitors and exclusion of
visitors with communicable diseases).
Limitations to visitation – strictly limit #s of visitors
Active screening for ILI
Other
Aerosol-Generating Procedures
Follow standard precautions and facility procedures for handling linen and
laundry and dishes and eating utensils, and for cleaning/disinfection of
environmental surfaces and patient care equipment, disposal of solid waste,
and postmortem care.
During procedures that may generate small particles of respiratory secretions
(e.g., endotracheal intubation, bronchoscopy, nebulizer treatment, suctioning),
healthcare personnel should wear gloves, gown, face/eye protection, and a fittested N95 respirator or other appropriate particulate respirator.
35
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
ALGORITHM 1 PANDEMIC
INFLUENZA Appendix ???
IN ADULTS
Cough, fever and/or influenza like
symptoms
NO
Temperature > 38oC,
immunosuppressed or over 75
Not flu. Advise on self-management at
home as per symptoms
YES
See Community Health Professional
NO
High risk of complications
(BOX) or severely ill
NO
Antipyretics, fluids
and self-care
advice*
Symptoms <2 days
YES
YES
Oseltamivir,
antipyretics, fluids
and self-care
advice*
Refer to GP
Is patient at high risk of
complications (BOX) or
severely ill (CRB-65 score
or clinical judgment)?
NO
Symptoms
< 2 days
NO
Investigation and
reporting as per
protocols†
Antipyretics, fluids
and self-care
advice*
YES
YES
CRB-65 (0-4, score 1 for each item present)
Age over 65
Confusion (e.g. MTS < 8)
Respiratory rate > 30/min
Blood pressure (SBP < 90 or DBP < 60
mmHg)
Oseltamivir,
antipyretics and
fluids and advice*
YES
If CRB-65 > 2, bilateral chest signs suggestive
of primary influenza pneumonia or other signs
of severe disease consider urgent referral to
hospital
Referred to hospital?
NO
Symptoms < 2 days
YES
Oseltamivir, antipyretics,
fluids and advice*
including back-up
prescription*. Optimise
co-morbid conditions.
NO
Antipyretics, fluids and selfcare advice* including backup prescription*. Optimise
co-morbid conditions.
Investigation and
reporting as per
protocols†
† Investigation and reporting protocols
Nose and throat swabs to be sent in virus transport medium to the local
Investigation and
reporting as per
protocols†
Further management in hospital
BOX
High risk of complications
Chronic disease (heart, renal, liver and respiratory), diabetes,
immunosuppressed, aged 65 or older, long-stay residential care
homes residents and others at doctors’ discretion.
*Advice
Including expected course of illness and warning signs of
complications

Shortness of breath at rest or while doing very little

Painful or difficult breathing

Coughing up bloody sputum

Fever for four to five days and not starting to get better (or
getting worse)

Started to feel better then developing high fever and feeling
unwell again

Drowsiness, disorientation or confusion.
Advice should also cover methods to minimize spread to others.
*Back-up prescriptions
for patients at high risk of secondary bacterial pneumonia for use
36
if worsening breathlessness or recrudescent fever.
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
ALGORITHM 2 PANDEMIC
INFLUENZA
IN CHILDREN
Cough, fever and/or influenza like
symptoms
NO
Treat at home with
antipyretics and fluids
Temperature > 38.5
YES
See Community Health Professional
(nurse or doctor if < 7 years)
NO
Age <1 year or child at risk of
complications (BOX)
Antipyretics
and fluids
NO
Symptoms <2 days
YES
Direct
attendance
YES
Oseltamivir,
antipyretics
and fluids
Refer to GP/A&E
Does the child have a
chronic disease (BOX) or
one of below features:
• Breathing difficulties
• Severe earache
• Vomiting > 24 hours
• Drowsiness
YES
Is child severely ill?
e.g. Signs of respiratory distress.
Markedly raised respiratory
rate
Grunting
Intercostal recession
Breathlessness with chest
signs
Cyanosis
Severe dehydration
Altered conscious level
Complicated or prolonged seizure
Signs of septicaemia – extreme
pallor, hypotension, floppy infant
YES
Refer for hospital
admission
Investigation and reporting protocols
Nasopharyngeal aspirate OR nose and
throat swabs to be sent in virus transport
medium to the local laboratory for early
cases. This will stop as cases increase.
Surveillance / reporting protocols will change
during pandemic, with less detail when case
numbers are higher.
NO
Is child < 1
year of
age?
NO
YES
NO
Antipyretics
and fluids
YES
Oseltamivir,
antipyretics
and fluids
Antipyretics
and fluids.
Review if
deteriorates
NO
Symptoms
< 2 days
Symptoms < 2
days and age >1
year?
NO
Antibiotic,
antipyretics
and fluids
YES
Oseltamivir,
antibiotic,
antipyretics
and fluids
BOX: Children at Risk for complications from Pandemic Influenza.
• Chronic respiratory disease including asthma (on inhaled steroids and
above),
cystic fibrosis, chronic lung disease of prematurity, bronchiectasis
• Congenital heart disease
• Chronic renal disease e.g. nephrotic syndrome, renal failure
• Chronic liver or Gastrointestinal disease including inflammatory bowel
disease
• Immunodeficiency
• Malignancy
• Diabetes and other metabolic conditions
• Haemoglobinopathy
Advice on limiting spread
Advice should be offered to cases and parents on
strategies to limit spread in the home and with
other contacts
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
SIGNS OF COMPLICATIONS
Designed and Implemented by the Pandemic Steering Council

Shortness of breath at rest or while doing very little
Revision #16
Last Revision date 7/30/07





Painful or difficult breathing
Coughing up bloody sputum
Fever for four to five days and not starting to get
better (or getting worse)
Started to feel better then developing high fever and
feeling unwell again
Drowsiness, disorientation or confusion.
ALGORITHM 3
COMPLICATIONS OF
PANDEMIC INFLUENZA
Refer to GP
NO
Other complication or
condition
Clinical diagnosis of
pneumonia /
secondary bacterial
LRTI
YES
NO
YES
Advice on self-care
Children – Secondary bacterial otitis media, bronchiolitis and croup with complicating
bacterial tracheitis are common.
Adults - Worsening of underlying co-morbid conditions are the most common non-
LRTI complications.
Refer to hospital if:
1. Primary influenza pneumonia – refer for assessment
Treat
and underlying conditions as usual.
including CXR. Suspect if dyspnoea or haemoptysis
earlycomplications
in
disease. Bilateral respiratory signs
2. Severe pneumonia based on 3 or more of the CRB65
criteria
3. Clinical assessment considering illness severity and
underlying condition, particularly if patient also meets 2 of the
YES
Further management in hospital
CRB65 criteria
CRB65 (0-4, score 1 for each item present)
Age over 65
Confusion (e.g. MTS < 8)
Respiratory rate > 30/min
Blood pressure (SBP < 90 or DBP < 60 mmHg)
Microbiology protocols
Early in pandemic sputum for gram stain
and culture if purulent sample available.
Once predominant complicating bacteria
identified in an area follow local empirical
therapy and microbiological investigation
only for cases not responding to empirical
therapy.
Referred to hospital?
NO
Primary care management of pneumonia
Microbiology as
per protocols
Empirical antibiotic therapy with co-amoxiclav to
cover expected organisms in pandemic for 7 days
Doxycycline (if age over 12) or macrolides as
alternatives if intolerant.
Management of co-morbid conditions
Clinical response
YES
Discharge
NO
Empirical antibiotics
Co-amoxiclav or Doxycycline are initial
empirical therapies of choice to cover
expected organisms ( S. pneumoniae, S.
aureus, H. influenzae). This will be altered
if other organisms are common or
particular resistance patterns support other
empirical therapy.
Investigate:
Sputum for gram stain and culture if available
Chest radiograph
Consider gram negative or Staph aureus pneumonia and
change therapy is appropriate
Referral to hospital if clinical condition warrants this.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
39
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? Scoring criteria for the Sequential Organ-Failure Assessment (SOFA)
score*
40
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ?? : Clinical Triage Guidelines
41
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
42
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ??: CDC Novel influenza A virus infections Case Screening and Report
2007 Case Definition (Source: Centers for Disease Control & Prevention, 3/22/07)
Clinical Presentation
An illness compatible with influenza virus infection.
Laboratory Evidence
A human case of infection with an influenza A virus subtype that is different from currently circulating human
influenza H1 and H3 viruses. Novel subtypes include, but are not limited to, H2, H5, H7, and H9 subtypes.
Influenza H1 and H3 subtypes originating from a non-human species or from genetic reassortment between animal
and human viruses are also novel subtypes. Novel subtypes will be detected with methods available for detection
of currently circulating human influenza viruses at state public health laboratories (e.g., real-time reverse
transcriptase polymerase chain reaction [RT-PCR]). Non-human influenza viruses include avian subtypes (e.g., H5,
H7, or H9 viruses), swine and other mammalian subtypes. Confirmation that an influenza A virus represents a novel
virus will be performed by CDC’s influenza laboratory.
Criteria for epidemiologic linkage: a) the patient has had contact with one or more persons who either have or had
the disease and b) transmission of the agent by the usual modes of transmission is plausible. A case may be
considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission
is laboratory confirmed.
Case Classification
Confirmed: A case of human infection with a novel influenza A virus confirmed by CDC’s influenza laboratory.
Probable: A case meeting the clinical criteria and epidemiologically linked to a confirmed case, but for which no
laboratory testing for influenza virus infection has been performed.
Suspected: A case meeting the clinical criteria, pending laboratory confirmation. Any case of human infection with
an influenza A virus that is different from currently circulating human influenza H1 and H3 viruses is classified as a
suspected case until the confirmation process is complete.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ??: CDC Human Influenza A (H5) Case Screening and Report Form
44
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
(Con’t.)
45
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ??: CDC Human Influenza A (H5) Case Screening and Report Form
(Con’t.)
46
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ??: CDC Human Influenza A (H5) Case Screening and Report Form
(Con’t.)
47
Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Appendix ??: CDC Human Influenza A (H5) Case Screening and Report Form
(Con’t.)
**
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
APPENDIX ?? : Home Discharge Instructions
Home Care Guidelines
Most patients with pandemic influenza will be able to remain at home during the course of their illness and can be
cared for by family members or others who live in the household. Anyone who has been in the household with an
influenza patient during the incubation period is at risk for developing influenza. A key objective in this setting is to
limit transmission of pandemic influenza within and outside the home.
Management of Influenza Patients in the Home
 Physically separate the patient with influenza from non-ill persons living in the home as much as possible.
 Patients should not leave the home during the period when they are most likely to be infectious to others
(i.e., 5 days after onset of symptoms).
 When movement outside the home is necessary (e.g., for medical care), the patient should follow
respiratory hygiene/cough etiquette (i.e., cover the mouth and nose when coughing and sneezing) and
should wear a mask.
Management of Other Persons in the Home
 Persons who have not been exposed to pandemic influenza and who are not essential for patient care or
support should not enter the home while persons are still having a fever due to pandemic influenza.
 If unexposed persons must enter the home, they should avoid close contact with the patient.
 Persons living in the home with the patient with pandemic influenza should limit contact with the patient to
the extent possible; consider designating one person as the primary care provider.
 Household members should be vigilant for the development of influenza symptoms. Consult with
healthcare providers to determine whether a pandemic influenza vaccine, if available, or antiviral
prophylaxis should be considered.
Infection Control Measures in the Home
 All persons in the household should carefully follow recommendations for hand hygiene (i.e., hand washing
with soap and water or use of an alcohol-based hand rub) after contact with an influenza patient or the
environment in which they are receiving care.
 Although no studies have assessed the use of masks at home to decrease the spread of infection, using a
surgical or procedure mask by the patient or caregiver during interactions may be beneficial.
 Soiled dishes and eating utensils should be washed either in a dishwasher or by hand with warm water and
soap. Separation of eating utensils for use by a patient with influenza is not necessary.
 Laundry may be washed in a standard washing machine with warm or cold water and detergent. It is not
necessary to separate soiled linen and laundry used by a patient with influenza from other household
laundry. Care should be used when handling soiled laundry (i.e., avoid “hugging” the laundry) to avoid
self-contamination. Hand hygiene should be performed after handling soiled laundry.
 Tissues used by the ill patient should be placed in a bag and disposed of with other household waste.
Consider placing a bag for this purpose at the bedside.
 Environmental surfaces in the home should be cleaned using normal procedures.
Source: U.S. Department of Health and Human Services. HHS Pandemic Plan. November 2005
Refer to Source on a regular basis for possible updates.
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
Plan Development:
1. Plan Background / Review (Steering)
2. Goals (Steering)
3. Planning Assumptions (Steering)
4. Decision-making structures for response (Steering)
5. Hospital surveillance (Steering)
6. Communication (Communication)
7. Infection control (Patient Flow)
a.
b.
c.
d.
e.
Standard Precautions
Isolation Precautions
Visitors
Cleaning, Disinfection and Sterilization
Environmental Cleaning
8. Education and training (Human Resources)
9. Patient triage (Patient Flow)
a. Home Discharge Instructions
10. Clinical guidelines (Patient Flow)
11. Use, administration and of vaccines and antiviral drugs (Pharmaceutical)
12. Surge capacity (Surge)
a. Staffing
b. Supplies
c.
Rooms
13. Mortuary issues (?)
14. Security/facility access (Patient Flow)
15. Human Resource Issues (Human Resources)
d. Staffing
e. Occupational health
16. Recovery of operations (I.T.)
17. Contacts - Authority and Responsibility (Steering)
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Saint Elizabeth Regional Medical Center
Pandemic Plan – A Working Document
Designed and Implemented by the Pandemic Steering Council
Revision #16
Last Revision date 7/30/07
+
INFLUENZA-LIKE ILLNESS - PROTOCOL ORDER FORM
+
PHYSICIAN ORDER
PATIENTS SEEN IN EMERGENCY DEPARTMENT WITH INFLUENZA-LIKE ILLNESS
DIAGNOSTIC TESTS
___ Pulse oximetry
___ Chest x-ray
___ Complete blood count with differential
___ Blood cultures: Gram stain, culture and susceptibility testing
___ Multivalent immunofluorescent antibody testing or PCR of nasopharyngeal aspirates or swabs
for common viral respiratory pathogens, such as influenza A and B, adenovirus,
___ Children: PCR of parainfluenza viruses, and respiratory syncytial virus
___ Adults with radiographic evidence of pneumonia: Legionella and pneumococcal urinary
antigen testing
___ Adults and children <5 yrs with radiographic pneumonia:
PCR for M. pneumoniae and Chlamydia Pneumoniae
___ Comprehensive serum chemistry panel, if metabolic derangement or other end-organ
involvement, such as liver or renal failure, is suspected
___ All of the following respiratory specimens should be collected for novel influenza A virus
testing: nasopharyngeal swab; nasal swab, wash, or aspirate; throat swab; and tracheal aspirate
(for intubated patients), stored at 4°C in viral transport media; and acute and convalescent serum
samples.
Admission Orders
___ Standard Precautions + Droplet Precautions.
IV solution:____________________________
Vital signs: ____________________________
O2: __________________________________
Activity: ________________________________
Diet: __________________________________
Medications:
Antivirals:
Antibiotic:
Home Meds:
Antipyretic:
Nurse Signature: _______________________________________
Date: __________________________________________
Fax this order form to Pharmacy.
Developed 10/06
Place Patient Label Here
51