ࡱ> ac`y 5bjbjEE 0L''-<!$2tEEEEE .Nb D2F2F2F2F2F2F2$946,j2  j2EE2EED2D2 /l1Ew0022021\8a8(l1l181n^PLnnnj2j2 nnn28nnnnnnnnn :  LMC Framework guidance on Practice Contingency Planning for Influenza Pandemic. Version 1.1 Please note that this document will be subject to revision and updating. If in doubt please check the LMC website to ensure that you have the latest version. 1.0 Background The Department of Health has asked practices to prepare plans for managing healthcare demand in the event of an influenza pandemic. It is likely that at some time the current H5N1 avian strain will make undergo an antigenic shift and become more readily transmissible between humans. Given the high natural infectivity of the virus this is expected to lead to a global pandemic of human influenza. 2.0 Epidemiology Experience of occasional seasonal peaks of flu infection suggest that viral spread is patchy. Some regions of the UK may have a high incidence, whilst others may show a lower or delayed peak in cases. Even within the county infection rates vary over time and between localities. There may therefore be some opportunity for sharing resources between localities to match immediate needs in different places. An H5N1 outbreak may not follow the usual seasonal pattern but is expected to last for many months with a likely peak incidence of new cases over perhaps 4-6 weeks . Practice plans should therefore anticipate extra work and disruption of normal activity for a substantial length of time There is likely to be more than one epidemic (with an interval of several weeks or months) and if a second wave occurs, it may be more severe than the first. The first wave may last between three and five months depending on the seasonal timing of first wave activity. Most estimates suggest that the pandemic is likely to originate in SE Asia and will take less than a month to reach the UK. Once the virus reaches the UK, it will take only a few weeks for the activity to be widespread. Estimates suggest that the cumulative clinical attack rate across all waves is likely to be in the region of 25% with mortality likely to exceed 50,000. Although various models have been tried, it is impossible to predict how this will translate into demand on practices 3.0 Information on Outbreaks Obviously the news media will cover this in depth, and the Department of Health will use the RCGP monitoring network to inform the NHS when there is a significant problem. The Health Protection Agency (HPA) will alert their local units, who will in turn inform GPs once a pandemic is declared.Given the ease and speed of travel around the globe, it is unlikely that an outbreak will be contained in its region of origin and infection will quickly spread. Practices need to have a plan that can be rapidly implemented . 4.0 Immunisation If there is time, the Department intends to distribute sufficient vaccine to immunise the whole UK population. Production is expected to take 4-6 months from the time the new strain is typed. At present the DH anticipates that 2 doses will be needed, probably 4-6 weeks apart, but if the antigenic shift is not as expected this may reduce to one, or even increase to three doses. However, for novel subtypes in a unprimed population a single dose is unlikely to provide adequate protection. Current estimates suggest that two standard doses may be necessary; the most likely dose is 2 15 mcg with adjuvant. Administering this will be the responsibility of practices, which presents a logistic challenge. If possible, we advise using a nearby but off-site venue such as a church hall or community centre, and allocating staff to this specific function only, probably working in shifts over an extended day, scheduled as supplies are delivered. Most patients are likely to present without the need for a call but you should have decided roughly how you are going to divide the practice population into suitable cohorts, perhaps by postcode especially if your practice area is large. 5.0 Escalation We strongly advise practices to have a formal escalation plan that can be implemented in stages as required. Some suggestions on the shape of this will be published in the LMC Newsletter. At some point in this the practice may recognise that they are no longer able to provide normal GMS/PMS as defined in their contract. You must inform the PCT of this promptly, and it would help if you could notify the LMC office. If a number of practices are in the same condition, then we can take steps to declare a Major Medical Incident. This has various planning and organizational consequences for the NHS ( for example, if agreed by an acute trust then all surgical work except cancer and emergency procedures is cancelled).It may also be helpful in the event of any contract or medicolegal problems that arise during its currency. 6.0 Triage In the event if a major outbreak, the peak incidence (about 6 weeks into the pandemic) is likely to be around 50 cases per thousand people per week. However, the number worried well, and patients contacting the practice with viral symptoms just in case is likely to substantially exceed this. You will not have the capacity to manage this demand in the conventional way, and should consider using telephone triage to use your resources most appropriately. A suggested protocol based on the original DH version will be posted on the LMC website. 7.0 Diagnosis Conventional virological diagnosis is prolonged and of no value in treatment decisions. A near patient test giving rapid results may be available in limited numbers soon, but diagnosis will largely rest on clinical criteria.. Given that the supply of oseltamivir will be limited some sort of agreed diagnostic standard will have to be agreed . One diagnostic algorithm suggests: There must be a PROSTRATING illness WITH fever over 38.5 AND at least one of cough, headache, sore throat, or myalgia 8.0 Infection Control It is clearly best not to encourage patients with active influenza to come to the surgery, especially as they will be infectious in the early stages of the illness when theyare still mobile. You should consider setting aside a part of the surgery, or using an alternative premises, for seeing patients with likely flu if a face to face consultation is required and dealing with them as rapidly as possible after arrival. Careful hygiene with frequent handwashing and alcohol gel decontamination is recommended, though face masks are of limited value and even the best probably only give protection for something like 20 minutes. Where possible, consider using specific doctors and nurses for this purpose ideally, of course, this would be someone who has had the current flu strain and recovered from it, but otherwise staff who have at least had conventional flu vaccination and who have the fewest other commitments in the form of dependent children or relatives. There may be a case for considering oseltamivir prophylaxis for key healthcare staff, but this is outside the scope of this paper. The suggestion that was made from the DH that patients would be visited at home by nurses has not been expanded upon and does not seem realistic at present. We understand formal guidance on infection control is currently being prepared nationally. There will be differences in the approach to this in the pre-pandemic and pandemic phases. 9.0 Treatment Oseltamivir needs to be taken with in 24-48 hours of the onset of illness to be effective. The PCTs should all by now have Patient Group Directives allowing it to be issued to patients by community pharmacists and nurses, and it is suggested that GP clinical resources be concentrated on children and at-risk adults, including the elderly. Patients in high risk groups should be offered prophylactic antibiotics, ideally co-amoxiclav, at their first consultation with instructions to start them in 24 hours if they are not improving. This would mean prescriptions for something like 2,000 packs of co-amoxiclav per week per PCT in Somerset, but so far we have no information on whether any sort of stockpiling is planned locally, nor to we know quite how supplies of oseltamivir will be distributed. Provisional microbiological advice is that tetracyclines, preferably doxycycline, and azithromycin are reasonable alternative antibiotics. 10.0 Supportive Care Hospital admission is unlikely to be an option, partly because of the need to try and prevent disease transmission, and partly because acute trust capacity will be overwhelmed within hours of a pandemic arriving. Patients will have to be managed at home, although national guidance suggests temporary intermediate care facilities might be found. It is hard to see quite how this is going to be done. 11.0 Maintaining Normal Clinical Services At the same time as coping with flu cases, practices will need to maintain at least some of their normal clinical activity. We anticipate that at the onset of the pandemic, demand for non-flu consultations will fall, only to rise again so that at the end of about 4 weeks it will be back to normal. We strongly advise practices to try and ensure that they are well up with QOF work in advance as things like routine asthma and diabetes clinic will almost certainly have to be suspended for a period. You also need to have a plan for continuing to provide a service when staff fall ill, or are not able to come to work because they are caring for sick relatives. Total Telephone Triage is likely to be a valuable tool under these circumstances, as face to face consultations can be restricted to the available number of appointments on the basis of need. Details of this are on the LMC Website. 12.0 Work Sharing If visiting need is very high, or some practices suffer high rates of doctor and nurse sickness there may be benefit in sharing resources for home visits. We suggest: Talking to neighbouring practices about whether this might be a practical option in your locality Buying some triplicate books for visit notes ( one to patient, one to home practice, one for doctor to keep) Talking to your PCT about how and where this might be co-ordinated. It is also probable that the OOH service would not be able to cope with prolonged high demand. Although the LMC would not wish to see all OOH responsibility revert to practices we may need to consider: Extended opening hours for practices (evenings, Saturday and Sunday mornings) Providing extra medical staff for PCT based OOH rota Locality based OOH cells ( i.e. old fashioned extended rotas) in the event of a catastrophic collapse of the OOHS 13.0 Recovery After a period of high intensity work, doctors and staff will need some recovery time before work can proceed at its normal pace. You should not expect to be able to resume full normal working for perhaps 6 weeks after the pandemic has subsided 14.0 Integrating plans with other agencies The LMC will attempt to ensure that PCTs overall plans fit with both practice local plans and the arrangements being made by other services including those of local hospital and ambulance trusts, local authorities, and funeral directors. 15.0 Financial implications Apart from direct costs such as staff overtime and sickness pay, QOF targets and meeting Enhanced Services contracts may not be achieved. Some costs, such as extra OOH work, may be partly recoverable from the PCT but this cannot be assumed. We advise that your financial planning looks at the possible impact of a pandemic on both cash flow and profitability. Dr Harry Yoxall November 2005 P]^_~ E vk`UkJkhhCJaJhh ^CJaJhhCJaJhh&CJaJh6h&CJaJh6CJaJhOCJaJh&CJaJh&5CJaJhVbb5CJaJh&5>*CJaJhO56CJaJhOhO56CJaJh565>*CJaJhO5>*CJaJh&h&5>*CJaJh56jh56U^_ E F g h bcCDSgd& '&#$/ I f g h k tucg,289OZ[aHJt|Ĺ{{{ss{sk``h6hXCJaJh6CJaJhYCJaJhhCJaJhXCJaJhXhX5CJaJhVbb5CJaJhhCJaJhhFCJaJhhVCJaJh6h ^CJaJh&CJaJhh6CJaJhh ^CJaJhh&CJaJhCJaJ! ^_bcghnr}~)EBCDSAB흒wnwfwfhOCJaJhyc5CJaJhycCJaJhcCJaJhhXCJaJhhFCJaJhhCJaJhCJaJhRCJaJh1)CCJaJhVbbCJaJhX5CJaJhVbb5CJaJhCJaJhhCJaJhXCJaJh6h&CJaJ'pqrz4:\˿ݮvnfn^U^^hm46CJaJhm4CJaJhVbbCJaJh\CJaJhVbbh\5CJaJhVbbh\56CJaJhVbbh56CJaJh1CJaJhycCJaJhYCJaJh5CJaJhh5CJaJhVbb5CJaJhyc5CJaJhCJaJhychycCJaJhOCJaJhOCJaJ##$$$V(W(l(***.*',(,---l.m..AFTuԟDO^Ff'^e{ L X/`}VF 4@7B_ս &h0`uos@K?R_g]ȗg)w_7WܔA  7W@W _#Q~/۫;ޔLw+Џm,^"`=@G@/Ce,^ mΖZr%eO,Q?hfxE‹Ebud̯S(Kޢʰ$QWPeFphg>h DŽbS6{C?(J+*%tPOΧؕN%#ٌF"Ҩ@#(# wRߒV?iw3BLt PRcwlC2JE4G!ep3@b=+aqM wxZp+-1K ]x/&ySGM 1#5]Vך7ܟ։l<XC@t#17 ݿE 7 鮄~U)uX[D5]eGFZ m8w%]6;4DQU|(ޡ9GLtz Qk<4olP|HRM Knߠ5-R*hQ=R[½U&/˄p :4eOVK'Npk䖤ՄLÁ <,&!bl)g DAlh7P&Ů5f+ Ϝ|/7@@'@f*bL8P-#k4ty mx FrR~?({H"DrUvDl< 7))ISuY5~z&bdJHX⩶>B ]^\XqJCڏj%q$ 9̚ri1(.qzbdAU@<递(Qgs XFRs*7 ( J4I!jz׎ a,PD;Ft ?-̣Z]@`ZH0wk  xmHDP2IbD~- =F@fgHP5"; phFK҈ZCX;B(:[Yڗ @ͣ00<!H5iV-Q5.RP}@(Џi϶b.Aw}IpʕC(jw腟dS$Rc;3 ޘ⪀]xse1Dޗht¤Ꞡm8 FFyUCV9]Y)PRY x"k>1HbA1MD/*c,1!9PODU2ֱXAKeW3-khj# *肄 [@ K2C2#OQ\>z-aojv/g71f`V/"!󔚏h$!.ʊԳMZ'X@?DU:Ыx׶1־Q@)!jіPFlv47v&t)_yJk4L l2yI8)Vjn {:~Gփ$MB G"X2rx\RH,Fw(9ϑ x16-/@_EL h^kИɸbE hh2xNf\؟ARLl?C u=n:c4bk[)ݢLQ+F(m/ ౓g>5q% -܄+,)*JQ$/&qh$Ψd|V9Z뤫tΑD< CUS(0fȇ&>0@A6[& lk+\ P̘0F! #*(LʿĈ^ s *PLNVJ3>!4lU~xkU}:`[a 6kW#3_\-so.^= JwX mF{9F(}}瀺y瀂kL'=Nt&@BRoGQ9'Ax\J^]ЖlTQdPh(NQД߹#nUY;H]Zٖ}@Y@89;U^`'ίfDUC9+Ql;!ædn$Qa5U&hKL !~$)62\anH1`t+?[ Ӕ: Sd:nj td[bHG3)j`T\F^U]~yK$z3Vcz!kNCY]9qaR <{+kKZ.9-VuPwbۛNG jZ;bO[/Il t\eW]w `^]1EK}\yVzW y+}#^`x~*뤑9Y}p'پKc6L(Zˢ@4h ZԽrR˰dNpݼSdsgV-W`% mgڢdOF;?2x]@I4.8fԍiZN{v=hҔ6㏒Wǀb'ADi0y 9}Vԝ:nc]1C@gCj(^l 22H͉.OaSz.P3cNEg(1kQd^s2M t22B̳h5"911Dt<拓tBWhZ?0ti8ߗThITS;|7584<5)X~I}j5HٰK{}[X@)MS#68PVde ?3~@}q웬.g.)]L 6vyطM6H3yZ 3nF\XR '͹ -2KfG=9xf:Q QgF@˭$sOh6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H Normal5$7$8$9DH$_HmH sH tH TT ] Heading 1$$5$7$8$9D@&H$a$ 5>*CJHH ] Heading 2$5$7$8$9D@&H$CJLL ] Heading 3$5$7$8$9D@&H$>*CJPP ] Heading 4 $5$7$8$9D@&H$^CJbb ] Heading 5.$$p5$7$8$9D@&H$^p`a$5CJDA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List HBH ] Body Text$5$7$8$9DH$a$CJ^C^ ]Body Text Indent $5$7$8$9DH$^a$CJ\R\ ]Body Text Indent 25$7$8$9DH$^CJbS"b ]Body Text Indent 3 $5$7$8$9DH$^a$CJPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] -L \W(g35!"$/55 #%8@0(  B S  ? OLE_LINK1 OLE_LINK2-^^- K( #: K( D#: K( &: K( ': K( D: K( , K( l K(  K(  !!   !!"-## ))"-B*urn:schemas-microsoft-com:office:smarttagscountry-region8*urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsplace (+     :C_jPY    ! - u'~'(() )-Q*EK  [ g _ j > ? /<ixny6EDTw !!!!!I"R"# ###n$x$(%())))**++,,-3333333333333333333333333333333333333  W l "."`&k&D)R)g++,---$[ 7PP;j=nWcjfPiiPtG>u* ^`hH ^`hH.  0 ^ `0hH.. \ 0\ ^\ `0hH... HH^H`hH .... ^`hH ..... `^``hH ......  <`<^<``hH.......  (#(#^(#`hH........ >^`>hH >^`>hH.  0 ^ `0hH.. s0s^s`0hH... ^`hH .... ^`hH ..... `^``hH ......   ` ^ ``hH.......  &&^&`hH........h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH 0^`0hH.0 0^`0hH. p0p^p`0hH.. @ 0@ ^@ `0hH... xx^x`hH .... HH^H`hH ..... `^``hH ......  P`P^P``hH.......  ^`hH........h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hH 0^`0hH.0 0^`0hH. p0p^p`0hH.. @ 0@ ^@ `0hH... xx^x`hH .... HH^H`hH ..... `^``hH ......  P`P^P``hH.......  ^`hH........fPip P;j= >uв 70 8] PtWcP8Tj30;41PLTj30;41PLTj30V;41PȝTj30;41Su@ ^`OJQJo(                  y"{o&%y gUI&O06J<1)CCIVXZ ^Vbbyc0,x15`D3c*]Y56Oc&O\m4RuFaYj--@^8 -@UnknownG* Times New Roman5Symbol3. * Arial?= * Courier New;WingdingsA BCambria Math"Ahv&v&`&Q`&Qxx24d-- 2QHX)?]2!xxK:\Templates\LOGO.DOT[LMC Framework guidance on Practice Contingency Planning for Influenza Pandemic. Version 1.1user Dr Anne Hicks(       Oh+'0$8 P\ |   \LMC Framework guidance on Practice Contingency Planning for Influenza Pandemic. Version 1.1user LOGO.DOTDr Anne Hicks2Microsoft Office Word@@@l@l`&՜.+,0P hp  0Somerset HealthQ- \LMC Framework guidance on Practice Contingency Planning for Influenza Pandemic. Version 1.1 Title  !"#$%&()*+,-./012456789:;<=>?@ABCDEFGHIJKLMNOQRSTUVWYZ[\]^_bRoot Entry FpdData '_1Table3/8WordDocument0LSummaryInformation(PDocumentSummaryInformation8XCompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q