Symposium on Pandemic Influenza - October 2007
By Mary-Katherine Sanchez, DrPH, MPH
History predicts that despite the severity of a pandemic, most individuals will survive without hospital or advanced medical care. In community pandemic planning efforts, it is clear that the availability of medical care through primary care physicians and community clinics will ease the surge of individuals attempting to obtain hospital care. The continued operations of primary care offices and clinics will also allow individuals who do not need advanced medical or hospital care to seek medical care outside of the hospital setting. Further, during a pandemic, patients will still require care and treatment for other illnesses and conditions such as minor injuries, obstetrics, vaccinations, and chronic diseases.
To date, physician offices have received limited guidance and recommendations regarding pandemic influenza planning. This article summarizes important aspects and considerations for outpatient clinics to provide continued care for patients during a pandemic.
We assume that during an influenza pandemic, transmission will be primarily through exposure to respiratory droplets and direct contact with patients and their contaminated environments. 1 Little or no immunity will exist, and few if any antiviral drugs will be available to fight the spread of infection. 2 The most effective way to reduce the spread of this virus will be through the practice of infection-control and social distancing measures.
While most hospitals already have disaster management plans, it is equally important for clinics and private medical offices to have plans as well. Early preparations and continuity of operations planning will be the key to maintaining and functioning during a pandemic. Every office should develop a pandemic influenza response plan as part of their continuity operations plan and should educate all staff members about this plan. Early preparations, as part of this plan should include:
- Developing and updating a business continuity plan to include pandemic response planning. According to the U.S. Department of Health and Human Services (HHS), a pandemic could reduce the available health care workforce by 30 percent to 40 percent; staff should be cross-trained to assist with essential office functions and responsibilities. Priorities should be established, addressing which duties are determined to be essential for operations and which ones can be delayed. Activities such as routine physicals and check-ups could be delayed until after a pandemic. A good starting point to begin this process is to use the U.S. Centers for Disease Control and Prevention (CDC) checklists online.
- Stockpiling additional infection-control materials such as gloves, masks, and cleaning supplies. Many hospitals and health care facilities operate with "just-in-time" inventory practices. But supplies may not be available, as a pandemic could disrupt supply lines. A suggested list of equipment and supplies has been proposed by the American Academy of Family Physicians (AAFP) (see www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/bt/fpfluchecklist.Par.0001.File.tmp/PanFluChecklist.pdf).
- Continuing to vaccinate all employees for seasonal influenza. Virtually every health care-based organization including CDC, the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and AAFP recommend annual seasonal influenza vaccination for all health care staff. This recommendation is more important during a pandemic, as it may help to differentiate the seasonal strain from the pandemic strain, as well as assist in maintaining as many available health care staff as possible.
- Educating patients about the need to develop their own pandemic influenza plan, as well as what important activities they should be undertaking for preparation. The Red Cross has created an excellent program on individual preparedness (available at www.redcross.org/news/ds/panflu ). Patients should be educated on how to prevent getting the flu, how to take care of ill family members, and what changes to expect during a pandemic. 3
Infection-Control Practices and Techniques
Infection-control practices include the use of personal protective equipment (PPE), hand hygiene, respiratory hygiene, cough etiquette, disinfecting hard surfaces, and social distancing. 2 During an influenza pandemic, infection-control practices are particularly important not only to health care professionals but also to patients and the public as a whole.
Gloves, Gowns, and Protective Eyewear
Gloves and gowns should be worn at all times when caring for a patient who may be ill with pandemic influenza, especially when coming in contact with respiratory secretions or other body fluids is likely. HHS recommends using gloves made of latex, vinyl, nitrile, or other synthetic material. 2 Gowns should be repellent to fluids and should be long-sleeved and cuffed. 3 They also should be large enough to fully cover the areas requiring protection. Gowns and gloves should be changed between patients and disposed of properly. Goggles, eyewear, and masks with shields should be worn for droplet precaution when sprays or splatter of infectious material is likely, such as during suctioning, nebulisation, bronchoscopy, or other aerosol-generating procedures. 4
Hand hygiene includes washing hands with soap and water, as well as using alcohol-based sanitizers such as gels and foams. Alcohol-based sanitizers do not require water and have been shown to decrease the spread of bacteria such as methicillin-resistant Staphylococcus aureus 4 and are also effective in killing many viruses such as influenza. 5 Hand hygiene should be conducted between patients, immediately after glove removal, and when hands may become contaminated by secretions or body fluids. 4 Make sure all patient care areas have adequate hand-washing facilities. This will prevent staff from possibly contaminating another area when washing their hands.
Masks have been shown to be effective in decreasing the spread of respiratory tract viruses. This was best shown among health care workers during the outbreak of severe acute respiratory syndrome (SARS). 6 Masks are effective in decreasing the spread in two ways: first, they decrease the number of droplets inhaled or deposited into the mucous membranes, and, second, they inhibit a person's ability to touch the nose and mouth, which can lead to self-inoculation. 2 The Occupational Safety and Health Administration recommends using a surgical or procedure-type mask in patient rooms or when within three feet of patients. Use of a fit-tested N95 respirator or equivalent is recommended when conducting aerosol-generating procedures. 4 Masks should be worn only once and then discarded. 2 Masks should be changed when moist. 4 Symptomatic patients should wear masks during transport to reduce the likelihood of droplet exposure.
Order for Putting On and Removing PPE
Depending on the situation and nature of the risk assessment, multiple personal protective equipment (PPE) items may be necessary. When using PPE, adequately train your staff to make sure the proper techniques and sequences are used when removing PPE, because improper removal can result in transmission of the virus. HHS and CDC recommend that PPE be put on in the following order: 4
- Respirator or mask
- Face shield or goggles
Upon leaving a patient's room or treatment area, HHS and CDC recommend removing PPE in the following order to avoid self-contamination: 4
- Face shield or goggles
- Respirator or mask
Even with PPE, you should take precaution to not touch your face with contaminated hands or gloves, which could transmit the virus to susceptible mucosal surfaces such as the eyes. 2 The use of gloves does not replace the need for proper hand hygiene.
During an influenza pandemic, surfaces and equipment in and around the clinic will need to be disinfected regularly. Health care workers should wear gloves when handling used patient care equipment and should wipe heavily soiled equipment hospital disinfectant approved by the U.S. Environmental Protection Agency before removing it from the patient exam room. Health care workers also should wipe external surfaces of portable equipment and all hard surfaces.4 Office staff should regularly disinfect hard surfaces in patient waiting areas such as chair arms, door knobs, tables, telephones, and the like.
For more detailed information on disinfecting, see the Environmental Services section in the Guideline for Environmental Infection Control in Health-Care Facilities, 2003, online at http://www.cdc.gov/hicpac/pubs.html. When disinfecting, it is also important to disinfect cleaning equipment such as reusable soft head mops, linens, rags, and towels.
Social Distancing in Triage Systems
Isolating or separating all patients by at least a three-foot margin until they are evaluated or triaged is generally recommended. 3 If possible, have separate waiting areas and entrances and exits for those individuals with flulike symptoms. Distribute respiratory prevention packets consisting of a disposable surgical mask, facial tissue, and cleansing wipes to all symptomatic patients. Consider rescheduling or postponing all routine appointments not needing immediate attention. Having patients telephone the office with their symptoms before arrival may enable staff to better plan for patient arrival and lessen the risk of exposure. 3
In summary, an influenza pandemic will tax health care resources beyond surge capacity. Supplies will be limited and hospitals may not be able to care for all patients because of high volumes and staff shortages. It is therefore vital to the health of the community and its constituents that private physician offices and clinics remain open to help alleviate the surge of individuals seeking care and treatment at hospitals.
Dr. Sanchez is the pandemic preparedness coordinator with the Dallas County Health and Human Services Department.
- American Academy of Family Physicians. Checklist to prepare doctors' offices for pandemic influenza. December 2006. http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/bt/fpfluchecklist.Par.0001.File.tmp/PanFluChecklist.pdf. Accessed July 11, 2007.
- Occupational Safety and Health Administration. Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. May 2007. http://www.osha.gov/Publications/OSHA_pandemic_health.pdf. Accessed July 10, 2007.
- Australian Government Department of Health and Ageing. Interim infection control guidelines for pandemic influenza in healthcare and community settings. Oct. 12, 2006. Accessed July 9, 2007.
- Johnson PD, Martin R, Burrell LJ, et al. Efficacy of an alcohol/chlorohexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust . 2005;183(10):509-514.
- Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guidelines for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep . 2002;51(RR-16):1-45.
- Seto WH, Tsang D, Yung RW, et al; Advisors of Expert SARS Group Hospital Authority. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet . 2003;361(9368):1519-1520.
October 2007 Texas Medicine Contents
Texas Medicine Main Page