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Influx of Infectious Patients Plan

PURPOSE:   To provide for an effective response to a real or risk of influx of infectious patients.  A separate Bioterrorism Plan is to be utilized if there is a suspected bioterrorism incident, and is part of the hospital disaster plan.

POLICY: In the event of a real or risk of an influx of infectious patients, the hospital will implement  a plan of response to reduce the risk of the spread of an infectious disease.  

Epidemic:  An excess over the expected incidence of disease within a geographical area during a specified time period. 

Influx of Infectious Patients: Presentation of a large number of suspected or confirmed infectious patients at the hospital that is in excess of the hospital's ability to provide routine treatment.

The Infection Control Nurse or  Designee  will monitor for potential epidemics or emerging, infectious public health threats, through routine surveillance of admissions, syndrome surveillance, and surveillance of microbiology culture results.  Communication with the local and state departments of public health and the CDC have been established through designated fax, Internet sites, and e-mails. If a potential epidemic or new infectious risk is identified, the Chief Executive Office, or Administrator on call, Chief Nursing Office, Emergency Department doctor, and the emergency department charge nurse will be notified to determine if the Influx of Infectious Patients Plan will be implemented.

National Electronic Disease Surveillance System
The CDC and its public health partners have implemented the National Electronic Disease Surveillance System (NEDSS).  The NEDSS electronically links and integrates a wide variety of surveillance activities, meeting necessary confidentiality and security requirements, and facilitates more accurate and timely disease reporting and enhanced public health use of disease information.  

State Electronic Disease Surveillance System
The North Carolina Hospital Emergency Surveillance System (NCHESS) is designed to improve
North Carolinas ability to recognize and respond to acts of bioterrorism, disease outbreaks, and other public health emergencies.  This effort requires near-real time collection of clinical emergency department (ED) data from North Carolina hospitals.
North Carolina Emergency Management has also implemented the North Carolina Hospital Surveillance System.  Each morning the designated employee enters the required information giving the state real-time census and bed status.   

The Infection Control Nurse is responsible for monitoring and responding to the NCDPH Health Alert Network, a network for communicable disease alerts throughout the state.

The Infection Control Committee collaborates with the Environment of Care Committee via the Infection Control Nurse and Facilities Manager, in partnership with local, state, and federal agencies to develop a hospital specific response plan to manage an influx of infectious patients.

Implementation: In the event of an actual or suspected influx of infectious patients, the Infection Control Nurse, Chief Nursing Officer, or Emergency Department charge nurse will notify the Chief Executive Office or Administrator on call of the need to implement the plan.

The ranking person outlined above shall function as the Infection Control Disaster Officer until the Chief Executive Officer and/or designee arrives.  The Chief Executive Officer will activate the appropriate Emergency Management Plan and assume responsibility as the Infection Control Disaster Officer upon arrival at the facility.

The PBX operator will, upon notification by the CEO will notify the following personnel:
a. Chief Executive Officer or Administrator on Call (if not already done)
b. Chief Nursing Officer
c. Facilities Manager (if not already done)
d. Assistant Administrator
e. Key Management as assigned

Based on specific recommendations from the Emergency Department Physician, the ED charge nurse will ensure that the appropriate physicians are notified of the situation.

Key Management or Designee will notify Department Managers.

Department Managers will be responsible for notifying their staff, and if needed, implement the Phase Recall if additional department staff is needed to ensure the continued operation of their department ensure that staff is called back as indicated.

The following issues have been identified that will be addressed for managing an ongoing influx of potentially infectious patients over an extended period of time:

A. Identification of the Infectious Agent
The Infection Control Nurse will establish communication with the local public health department.  Identifying the infectious agent and establishing the likely mode of transmission will be a priority.  Infection control measures will be established to contain the infection at the point of entry into the facility.  This will include Droplet, Contact and Airborne Precautions as indicated.
B. Education and Communication with Staff will be a High Priority
If indicated, advisory signs for arriving patients and visitors will be placed at the facility entrances instructing patients exhibiting symptoms or those who have risk factors to immediately notify Emergency Department staff of any possibility of infectious illness. 

C. Personal Protective Equipment Guidelines- (Can be found in the Infection Control/Employee Health Manual)
Employees will be notified as to the appropriate level of precautions needed with all patients, visitors, and staff, if any additional precautions are advised in addition to standard precautions.
Recommendations for Avian Influenza:{WHO}
Mandatory if in direct close contact if close contact with patient is anticipated and for all aerosol-generating procedures.
N-95 mask required
Eye protection (face shield, visor or goggles) if close contact with patient is anticipated and for all aerosol-generating procedures.
Clean, non-sterile, ambidextrous gloves that cover the cuff of the gown
Clean, non-sterile long sleeved gown (fluid-resistant preferred)
D. Bed Availability
Each inpatient unit as outlined in the hospital Emergency Management Plan will prepare a list of inpatients that may be discharged.  
Physicians will be contacted to discuss the need for:
1. Possible discharge of inpatients 
2. Possible transfer of inpatients to another unit
3. Ceasing all non-emergent hospital admissions
4. Canceling all non-urgent surgeries

E. Admissions
Elective admissions will be cancelled until the epidemic of influx of infectious patients is determined to be under control.

F. Staffing/Phase Recall
Staffing levels may be adjusted as needed to provide adequate patient care.  Disaster recall may also need to be implemented as defined in the hospital Emergency Management Plan.

G. Temporary Treatment Areas
Temporary treatment areas, such as the Outpatient lobby, may be used to treat outpatients presenting for treatment, i.e. influenza.  

H. Pharmaceuticals and Medical Supplies
Medications and supplies will be provided, as indicated, and as outlined in the hospital Emergency Management Plan.

I. Lab Specimen Collection
Microbiology staff will consult with the state health department for recommendations regarding specimen collection, containment, and transport.

J. Isolation
Isolation within the hospital will depend on the number of patients involved.  A small number of patients can be isolated in existing isolation rooms and/or halls on the nursing units, depending on the disease and the required level of precautions.  Larger numbers of patients will necessitate the conversion of a nursing unit to an isolation unit. The decision to convert a nursing unit to an isolation unit will be made collaboratively by representatives from Administration and the Infection Control Nurse. Patients with potential exposure, who may be incubating the infection, will need to be identified and separated from patients with active, symptomatic cases.  Isolation Precautions (Contact, Droplet, or Airborne) will be initiated based on the likely mode of transmission.  In the event a patient will not comply with isolation precautions or seeks to leave AMA, the Department of Public Health will be notified.  The Department of Public Health will be responsible to investigate the case and pursue an emergency isolation order.  The Administrator on call will be notified if the county issues an isolation order.

The following standards will be utilized when implementing isolation or quarantine:
1. Utilize appropriate levels of CDC transmission-based precautions.  If airborne isolation is required, conduct verifications that the airborne isolation room is under negative pressure to adjacent areas throughout every shift. The negative pressure rooms equipped with alarms and anterooms are ED Room 1, 214, 215, 224, 225, ICU 2004, 305, 314, 315, 324, and 325. 
2. A Hepa-filter unit is available.  This can be used in the event that a negative pressure room is not available.  (Stored in the Outpatient Surgery Area)
3. Personal protective equipment, including gloves, gowns, masks, N-95 masks, face shields, and foot coverings will be identified through each hospital's infection control plan or the local public health agency at time of incident.  If the use of a N95 mask is indicated, staff must have completed a successful fit-test annually, prior to donning the mask.
4. The Infection Control Nurse will make recommendations for the disposal of linens and medical waste based upon guidance from local and state health departments.

K. Employee Health Services
The Unit Managers and the Infection Control/Employee Health Nurse will monitor staff for symptoms specific to the suspected infectious agent. The Infection Control/Employee Health Nurse will consult with the Employee Health Medical Director for recommendations for prophylaxis of exposed staff based on the suspected infectious agent.

L. Visitors
Hospital visitors will be restricted during implementation of the Influx of Infectious Patients Plan.  Visitors will be restricted to immediate family and only as needed to stay with patients such as elderly patients, children, or confused patients.  Signs will be posted at all entrances to the hospital regarding visitor restrictions.  Non-compliant visitors will be reported to the local public health department.

M. Community Communication and Warning
In the event the Public Health Department issues a community warning NOT to come to the hospital unless absolutely necessary, newspaper, radio, and television notices will be utilized to communicate the warning to the public.  The Director of Marketing or designee will oversee public communication warnings.

N. Patient Discharge
Patients affected by the epidemic or infection will be discharged from the hospital when their medical condition warrants.  Discharge planning will be done for instructions on appropriate use of barrier precautions, hand hygiene, cleaning and disinfecting the environment, and patient care items in the event other persons may be exposed following discharge.  Discharge instructions and instructions for follow-up care will be provided to patients and their caregivers upon discharge.  

 **Actions taken above may or may not be warranted based on the situation as it unfolds. 


State Department of Health
Contact the General Communicable Disease Control (GCDC) Branch immediately at 919-733-3419.  If it is after hours, leave a message and the on-call epidemiologist will return the call as soon as possible.

Richmond County Health Department
910-997-8300 during normal working hours.  Tommy Jarrell, Director  
If after hours call 911 and ask for the On-Call person 

Hamlet Police Department---910-582-2551

Richmond County Sheriff---910-997-8283

Richmond County Emergency Management---910-997-8238

Infection Control Recommendations for Avian Influenza (AI)
From the World Health Organization (WHO)

Standard Precautions for all health care facilities, including
 Hand Hygiene
 Respiratory hygiene/cough etiquette 
 Early recognition, isolation and reporting of possible Avian Influenza
 Isolation precautions for suspected or confirmed AI-infected patients
 Duration of infection control precautions 
 Adults and adolescents>12 years of age-implement precautions at time of admission and continue for 7 days after resolution of fever
 Infants and children < 12 years of age-implement precautions at time of admission and continue for 21 days after illness onset (young children can shed seasonal influenza virus at high titers for up to 21 days.)
 Specimen collection/transport within healthcare facilities
 Must be placed in leak-proof biohazard specimen bags
 Staff should be trained in safe handling and cleanup in case of spill
 Specimen should be hand delivered where possible
 Staff should wear full barrier protection
 The requisition should be clearly labeled as (suspected) AI and lab notified that the specimen is on the way.

 Family member/visitor recommendations-should be strictly limited 
o Visitors should be provided PPE for full barrier precautions and hand hygiene practices reviewed
o Symptomatic visitors should be considered possible AI cases and should be evaluated for AI infection.
 Patient transport within health care facilities
o Limit the movement and transport as much as possible
o If transport is necessary, the patient should wear a surgical mask and perform hand hygiene after contact with secretions
o All surfaces should be cleaned and disinfected after the patient has had contact
 Waste Disposal
 Use standard precautions when working with solid waste than may be contaminated with AI Virus
 Dishes and eating utensils
 Use standard precautions for handling these items
 Linen and laundry
 Use standard precautions for handling these items and place linen directly into laundry bag in the isolation room
 Environmental cleaning and disinfection
 Cleaning MUST precede disinfection
 AI virus is inactivated by a range of disinfectants including:
 Phenolic disinfectants
 Quaternary ammonia compounds
 Peroxygen compounds
 Household bleach
 Alcohol
 Patient Discharge
 If discharged while possibly still infectious, family members should be educated on personal hygiene and infection control measures.
 Family members should be educated to avoid poultry and other animals that have been ill and how to self-monitor their health status.
 Terminal cleaning of the patient room should be performed.
 Care of the deceased
 Use standard precautions for routine care of the body
 The body should be fully sealed in impermeable body bag prior to removal from the isolation room.
 If the family wishes to view the body, they may be allowed to do so.  If the patient dies during an infectious period, the family should wear gloves and gowns and perform hand hygiene.
 Cultural sensitivity should be practiced when an AI patient dies.
 Notify the mortuary staff that the deceased had AI.  They should observe standard precautions when handling the body.

Reference:  WHO 2008 -Epidemic and Pandemic Alert and Response           
                                 World Health Organization, CH-1211 Geneva- 27 Switzerland. 2008