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Case Study Module 4 Part 2 Patient Management 1 Case Management of Suspect Human Avian Influenza Infection Part 3: Triage of Suspected Avian Influenza Cases 2 Learning Objectives • Define triage • Know the function of each of the four steps in a triage approach • Recognize the utility of triage in avian influenza case management 3 Session Outline • Triage and pneumonia severity ratings • Assess the level of care needed • Assess available healthcare facilities • Advise on referral and transport of patients • Assess illness in contacts, determine whether to recommend treatment or isolation of cases, contacts 4 Triage Defined • Triage is a system of carefully using medical resources where they are needed most – Decisions about who is the most ill – Decisions about who will respond best to care 5 Steps for Triage of All AI Cases Steps Example Determine type and severity of illness 1. Patient has pneumonia Assess level of care needed 2. Does the patient need Antivirals? Oxygen? A ventilator? Assess available health 3. care resources Does the health care facility have a ventilator? Advise on patient referral Does a nearby facility and transport have a ventilator? Can 4. the patient make the trip? 6 Triage Step 1 Determine Type and Severity of Illness 7 Determining Severity of Illness • For avian influenza, prioritize by severity of pneumonia • Systems for rating pneumonia severity – Pneumonia Severity Index – CURB-65 – Pneumonia Severity Scoring System • Scores assigned to show urgency of hospital admission 8 CURB-65 • • Developed the British Thoracic Society One point each for: – Confusion (new disorientation in person, time or place) – Urea, or blood urea nitrogen (BUN) level above 7 mmol/L (urea) or 20 mg% (BUN) – Respiratory rate >= 30 breaths/min – Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic – Age >= 65 years Source: http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/btsscore.ht9 m CURB-65 Interpretation Score Predicted Mortality (%) 0 1 2 3 4 5 0.9 1.1 5.2 12.0 32.4 25* * low numbers and very broad confidence interval Score 0: Low risk of death; may be suitable for home treatment Score 1: Increased risk of death; consider hospital referral and assessment or home treatment Score 2: Increased risk of death; consider for short inpatient treatment or supervised outpatient Score >=3: High risk of death; Require urgent hospital admission 10 CRB-65 Interpretation Score Predicted Mortality (%) 0 1 2 3 4 0.9 5.2 12.0 32.4 25* * low numbers and very broad confidence interval • CURB-65 scoring, without lab test for Urea (blood urea nitrogen) • Has not been confirmed in large studies 11 Pneumonia Severity Ratings • Do not rely solely on scores – Scores serve as a guideline – Consider the patient’s clinical information – Use best judgment based on expertise • Adapt rating systems to local capacity – Pulse-oximetry to measure oxygen in blood – Availability of blood pressure monitors 12 Pneumonia Severity Rating Systems Question 1 What elements of the rating systems do you think are most useful? Question 2 How might the system be adapted for your area? 13 Case Report 14 A Patient in China • Female, unknown age, 4 months pregnant • Presents at hospital November 7 • Symptoms – – – – – – – Trouble breathing Cyanosis (blue-colored skin) Fever 38.8°C Pulse 118 beats / minute Respiratory rate 37 breaths / minute Lymphocyte count 608 / mm3 Chest x-ray shows diffuse infiltrates in the lower part of both lungs 15 Rate Pneumonia Severity CRB-65 Category Confusion Points Given 0 Respiratory rate >= 30 breaths/min 1 Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic [Pulse > 125 beats / min] 1 Age >= 65 years 0 Total Points for modified CRB-65 2 Moderate risk of death; consider hospital admission 16 Triage Step 2 Assess Level of Care Needed 17 Hospitalization Not Needed • Patient may be cared for at home • Administer appropriate antiviral if avian influenza suspected • Teach patient and family – – – – Wash hands Ill person uses a surgical mask Limit social contacts Symptoms in patient or family members that require prompt medical care • If possible, follow-up with home visits or by telephone 18 Hospitalization Required • Illness is not an emergency – Monitor for changes in status – Treat with antiviral – Treat as necessary with • Antibiotics • Oxygen • Severe illness – Patient admitted to intensive care unit – Ventilation or advanced medical support for organ failure may be necessary 19 Triage Step 3 Assess Available Healthcare Resources 20 Healthcare Facilities Clinic • Local level • Community healthcare • Outpatient services Hospital • Local or district level • More laboratory capacity • Inpatient services Referral Hospital • Larger cities • Advanced medical care • Laboratory diagnosis • Isolation rooms 21 Healthcare Facilities Know your area facilities: – Location – Capability – Capacity 22 Healthcare Facilities Question 1 What healthcare facilities are available in your area? Question 2 What level of care can be provided at these facilities? 23 Triage Step 4 Advise on Referral and Transport of Patients 24 Referring Patients to Another Facility Logistical considerations • • • • • Treat all patients at one versus a few sites? When to transport patients to higher level facilities How to transport patients to higher level facilities Staff availability Availability of overflow areas Treatment considerations • • • • Access to antivirals and antibiotics Access to a laboratory for diagnosis Access to radiology (x-ray) Availability of isolation rooms 25 Patient Transport Example Female patient, Thuy, with pneumonia admitted to primary level hospital • The only patient suspected of avian influenza • Symptoms: fever, high pulse and respiratory rate, crackles heard in lungs • Primary hospital can administer oxygen and antibiotics, but has no access to x-ray or antivirals • Tertiary hospital can x-ray patient and place on ventilator support, if needed, but has no antivirals 26 Patient Transport Example Question 1 Would you recommend transporting Thuy to the tertiary care hospital? Question 2 What if Thuy was one of many severe pneumonia patients at the primary hospital? Question 3 What do you think are the most important criteria for deciding to transport a patient? 27 Problem Solving Exercise 28 Public Health Steps for Managing Cases 29 Additional Steps Necessary 1. Assess presence of illness among contacts 2. Advise on management of corpses with possible avian influenza 3. Determine need for isolation and quarantine 4. Document data on standardized forms and report to relevant authorities 30 Assess Contacts • Assess contacts quickly – Incubation period only 2 to 3 days • Contact - anyone who has touched or talked with (=<1 meter) the patient up to 2 or 3 days prior to the patient’s onset of illness – Household members – Fellow workers • Assess contacts for influenza-like illness – – – – Fever Cough, shortness of breath Muscle aches Diarrhea 31 Manage Corpses • No risk of transmission from dead bodies • Autopsy procedures could result in transmission – Use appropriate protective equipment • You should know – Where corpses may be sent for disposal – Cultural or religious beliefs to respect when handling corpses 32 Advise on Isolation and Quarantine Isolation • Separate or limit movement of people who are ill to prevent them from infecting healthy people • Often occurs in a healthcare setting • For use when illness is fairly rare Quarantine • Separate people who have been exposed to an illness (may not be ill themselves) • For use when illness is widespread • May cancel public gatherings, large events 33 Advise on Isolation and Quarantine Length of time for isolation and quarantine depends on incubation period and infectious period Goals: – Prevent additional human cases early – Slow pandemic spread (gain time for preparing) – Reduce the impact of the first wave of a pandemic 34 Document and Report Cases • Help identify and describe old and new strains of avian influenza • Know where avian influenza is being transmitted • Track and count illness due to avian influenza • Provide information for influenza control • Help officials make public health decisions 35 Document and Report Cases World Health Organization Ministry of Health District or Provincial Level Local Level 36 Document and Report Cases “WHO Guidelines for Global Surveillance of Influenza A/H5” http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf Annex 5 “Template for Case Report Form” 37 Document and Report Cases Information to include • Name of person reporting • Healthcare facility name and location • Patient information: Demographics Symptoms Test Results Treatment given Travel history Avian flu in area animals Potential exposures Outcomes 38 Document and Report Cases 39 http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf Document and Report Cases When should you report? • As soon as possible! • Do not wait for laboratory confirmation • Do not wait to observe patient outcome 40 Summary • Patients needing advanced care may need to be transported to a higher level facility, while patients with mild illness may be able to stay at home • Medical treatment and care of patients will depend on the facilities available in your geographic area • People who have contact with a suspected avian influenza case should be assessed for illness, and may be given preventive treatment or put in isolation 41 Case Study Scripted Role Playing Activity 42 Glossary Triage A system of carefully using medical resources where they are needed most. 43 References and Resources • WHO interim guidelines on clinical management of humans infected by influenza A(H5N1), 2 March 2004. http://www.who.int/csr/disease/avian_influenza/guide lines/clinicalmanage/en/index.html • Tran Tinh Hien, et al. Avian Influenza A (H5N1) in 10 Patients in Vietnam. N Engl J Med March 18, 2004: 350(12), p 1179-1181. • WHO pandemic influenza draft protocol for rapid response and containment Updated draft 30 May 2006. http://www.who.int/csr/disease/avian_influenza/guide lines/protocolfinal30_05_06a.pdf 44