ࡱ> [ cbjbj &ΐΐZX X DSSS SЙ(!!!4!>r!! suuuuuu&u& @4!&&u!!5*5*5*&R!!s5*&s5*5*c"!@S'P_0Й;Dk(`!d"5*#$!!!uu)j!!!Й&&&&!!!!!!!!!X a:  XXXXXXXXXXXXXXXXX PRACTICE INFLUENZA PANDEMIC PLAN Strategy and actions to be taken by the practice in the event of an outbreak of a pandemic strain of the influenza virus Plan prepared by: XXXX XXXXXXX CONTENTS Page 1. Introduction 2. Management of the response 2.1 Strategy 2.2 Responsibilities 2.4 Buddying arrangements 2.5 Out of Hours cover 2.6 Support to other organisations 2.7 Staff training 2.8 Patient and staff communications 2.9 Staff welfare 2.10 Sickness reporting and return to work 3. Clinical pathway 3.1 Triage 3.5 Triage responsibilities 3.6 Use of antiviral medication 3.9 Death certification 4. Infection control 4.2 Cohorting and segregation of patients and staff 4.3 Visiting regular patients 4.4 Visiting flu patients 4.5 Personal Protective Equipment 4.8 Hand hygiene 4.9 The coughing and sneezing patient 4.10 Facemasks 4.11 Gloves 4.12 Aprons 4.13 Eye protection 4.14 Aerosol generating procedures 4.15 Cleaning and disinfection 5. Business continuity 5.1 Business Continuity Plan 5.3 QOF arrangements Appendices Appendix A Patient and Staff communications material Appendix B Influenza pandemic segregation plan Appendix C Cleaning schedule Appendix D Business Continuity Plan 1. INTRODUCTION 1.1 Pandemic flu is a type of influenza that spreads rapidly to affect most countries around the world. It can occur at any time of the year, not just winter. History shows that pandemics of influenza have occurred three times in the last hundred years. Experts predict another pandemic will occur but cannot say when. When it does it will come in one or more waves several months apart, each wave lasting two to three months. 1.2 Pandemic flu is more serious than ordinary flu. Whilst the symptoms may be the same as ordinary flu the impact may be more severe as most people will have little or no immunity to the virus. A serious pandemic is likely to cause many deaths, disrupt the daily lives of many people and cause intense pressure on health and other services. Everyone will be at risk of catching pandemic flu. Until the virus is circulating it is not possible to predict the groups most at risk or the proportion of the population likely to be affected. 1.3 This plan sets out the action to be taken by the XXXXXXXX practice in the event of an outbreak of an influenza pandemic. The plan is to be activated when United Kingdom Alert Level 1 is reached. The United Kingdom alert levels commence only when the pandemic has been identified by the World Health Organisation (WHO) and WHO Level 6 has been reached. The different alert levels and general actions required are as follows: UK Alert DefinitionPractice Actions1 Virus or cases only outside the UKStaff with specific responsibilities to refresh and prepare to implement actions required at alert levels 2 to 4 Brief practice staff about the plan, including identified training Implement planned pre-emptive procedures in connection with repeat prescriptions, clinics etc. Review stock levels for Personal Protective Equipment and cleaning and disinfection materials and prepare for infection control. Finalise preparations for the arrival of the pandemic 2Virus isolated in the UK If isolated within the PCT area, go to level 3 actions, otherwise: Increase vigilance and surveillance for potential local cases Implement measures to maintain core services and prepare for potential disruption3Outbreak(s) in the UK Full implementation of the practice plan4Widespread activity across the UK 2. MANAGEMENT OF THE RESPONSE Strategy 2.1 The strategy for the XXXXXX practice will be as follows: To manage the impact of an influenza pandemic on the practice, To provide adequate healthcare during an influenza pandemic making effective use of potentially scarce healthcare skills, facilities and resources. Responsibilities 2.2 The Senior Principal will be responsible for the implementation of the strategy, assisted by the Practice Manager. 2.3 Other specific responsibilities are as follows: ResponsibilityPerson responsiblePandemic Infection Control LeadCOSHH assessment and discussion of proposed pandemic arrangementsArrangements for enhanced cleaningPPE supplies and issuesAntiviral AdministrationQOF Monitoring Buddying arrangements 2.4 Refer to guidance notes to complete this section Out of Hours cover 2.5 Refer to guidance notes to complete this section Support to other organisations 2.6 Refer to guidance notes to complete this section Staff training 2.7 The following staff training will be delivered upon notification of UK Alert Level 1 being reached: Training RequiredTraining delivered by:Staff to be trainedPPEInfection controlPatient pathwayVaccination Patient and staff communications 2.8 Refer to guidance notes to complete this section. Cross reference to Appendix A. Staff welfare 2.9 Refer to guidance notes to complete this section Sickness reporting and return to work 2.10 Staff who become unwell must be sent home during the period when they may be infectious to others (from as soon as they are aware of the infection until their symptoms resolve), unless staff shortages are extreme and they volunteer and are well enough to work in settings caring only for those with flu. 2.11 Some staff may fall ill with flu early on, yet recover and be fit enough to return to work with presumed immunity. Such staff should be posted in the front line of dealing with flu patients. Whilst there will be no need for them to take added personal precautions against flu infection, they will still need to be wary of other potential infectious diseases and take the standard precautions as the situation requires. Staff must continue to avoid carrying flu from an infected to an uninfected patient, so there can be no relaxation in hand hygiene standards, for example. The same will apply to staff who have been successfully vaccinated against the pandemic strain, when this becomes available. 3. CLINICAL PATHWAY Triage 3.1 The underlying principle for the treatment of patients who appear to be infected with the influenza pandemic virus is they should remain at home and be treated at home as far as possible. An indication of the likely impact of the influenza pandemic on this practice at the peak week of the pandemic is as follows: Practice Population of X,XXXNumbers at attack rate of 35%Clinical CasesGP Consultations: ComplicationsGP Consultations: Under 7sTotal Hospital AdmissionsMortality: Least caseMortality: Worst case 3.2 The triage arrangements within the practice will therefore be based on the following principles: Patients contacting the practice to report non-flu like conditions should be processed in the normal manner, including an appointment to attend the surgery if appropriate. Patients contacting the practice to report flu like symptoms will be advised to stay at home and contact the National Flu Hotline for advice, unless the patient also appears to fit any of the following categories: They are suffering influenza complications They are under 23Kg (usually children aged seven years and under) They have underlying medical conditions They are in identified at-risk groups: people aged 65 and over people aged under 65, but with chronic respiratory disease chronic heart disease chronic renal disease immunosuppression due to disease or treatment diabetes mellitus people of any age living in a long stay residential and nursing homes or other long stay care facilities They are not responding to treatment 3.3 Patients contacting the practice to report flu like symptoms and who fit any of the categories listed above in paragraph 3.2 will be advised to stay at home and will be added to a list for home visiting by a GP or other healthcare professional. 3.4 The identification of specific at risk groups may only become apparent as the pandemic develops and the specific effects of the virus can be seen Triage responsibilities 3.5 Refer to guidance notes to complete this section Use of antiviral medication 3.6 A national stockpile of Tamiflu (Oseltamivir), sufficient to treat 25% of the UK population, will be released to Primary Care Trusts at UK Alert Level 1. A quantity of Tamiflu will be made available to the practice through arrangements made by the Devon Primary Care Trust. For most patients, the intention is for them to obtain Tamiflu through a national flu helpline and designated distribution centres. For patients meeting the requirements for a home visit, Tamiflu will be provided by the visiting GP or other healthcare professional. 3.7 The practice allocation of Tamiflu will be obtained from (Details to be provided). The Practice (enter postholder detail).. will be responsible for arranging the collection, storage and allocation of Tamiflu within the practice. 3.8 For patients weighing less than 23Kg, usually children under seven years, an assessment will be needed to determine the appropriate dosage of Tamiflu to be given in suspension form. Death Certification 3.9 Refer to guidance notes to complete this section 4. INFECTION CONTROL 4.1 National guidance is that, in general, patients with pandemic flu should not attend the GP surgery. However it is likely that staff will be deployed to provide care to patients with influenza-like illness in other settings. Cohorting and segregation of patients and staff 4.2 Refer to guidance notes to complete this section. Cross reference to Appendix B. Visiting Regular Patients 4.3 Because of flu-related pressures, home visiting will need to be kept to a minimum, and the possibility of the visiting health worker introducing flu to the housebound and vulnerable should be part of the risk assessment before deciding to visit. When a visit is unavoidable, then a face mask should be to hand in case the person visited turns out to have symptoms of cough and sneezing. Otherwise, usual infection control procedures should be employed. Visiting Flu Patients 4.4 When patients with flu, or suspected flu, are to be visited at home, a face mask should be donned on entering the premises, and other protective equipment such as gowns and gloves used as necessary according to the procedures being undertaken. On leaving, all such equipment should then be discarded (the normal domestic waste system will do), and hands washed, using a personal hand gel dispenser if no wash-hand basin and soap are available. Alcohol rub can also be employed again after finally leaving the premises, for example, on returning to the car. Personal Protective Equipment (PPE) 4.5 PPE such as gowns, masks, gloves should continue to be used as normal with patients not thought to have flu when the exposure justifies this. Supplies within the practice may need to be rationed so this standard use is not compromised. If supplies become unavailable, a judgment will need to be taken within the practice whether some high risk procedures are best postponed. 4.6 There may be shortages in personal protective equipment, and available stocks will need to be used sensibly. In practice, this means that equipment cannot be used for all patient contacts and must only be used in managing those suspected to have flu symptoms or known to have flu. Supplies must also be reserved for dealing with patients known to have other serious transmissible infections and especially for standard universal precautions for handling blood and body fluids. 4.7 As with other infections, sensible choice of work attire may help to reduce the spread of infection. The wearing of ties is discouraged. Hand Hygiene 4.8 Frequent hand-washing, and at least once between each patient, is good practice in any case and should continue whether or not the patient is thought to have possible flu. In the absence of adequate washbasins in areas adapted for clinical care, wall dispensers for alcohol-based hand rubs or gels are an adequate substitute, though vulnerable to shortages in rub or gel. Staff from the practice involved in home visits need to have personal alcohol hand rub, and know how to use it correctly. The Coughing and Sneezing Patient 4.9 During the pandemic, there will be national media messages about the importance of covering the nose during sneezing, the safe disposal of tissues and other aspects of containing respiratory secretions, and the associated hand hygiene. If patients with symptoms of cough and sneezing attend the practice, they should be given a surgical face mask. Adults accompanying children and babies should be instructed on respiratory hygiene single use tissues and hand hygiene. Face masks 4.10 Staff within a metre of a patient known or thought to be ill with flu should wear a fluid repellent surgical face mask. A surgical face mask will provide a physical barrier and minimise contamination of the facial mucosa by large particle droplets, one of the principle ways influenza is transmitted. In the practice setting, face masks are likely to be needed by healthcare workers only, with receptionists for example ensuring they keep the distance from any relevant patients. National guidance is that this mask should be changed when moving between areas where flu and non-flu patients are cared for, or when they become moist. Gloves 4.11 Gloves are not strictly needed for the routine care of patients with pandemic flu, but are advised in national guidance provided sufficient supplies are available. Their use should be prioritised towards standard universal precautions for procedures such as dressing wounds and other activity that risks direct contact with excretions, body fluids etc. They need to be discarded after each patient use, and hands then washed and dried using paper towels. Alcohol hand-rub can also be used for decontamination of socially clean hands. Aprons 4.12 Aprons will be required if there is a risk of soiling or splashing. If a patient with flu symptoms is being examined, the national guidance recommends the wearing of an apron to reduce the risk of contamination of personal clothing. If supplies are sufficient, this should be used once only, and then discarded. When supplies are limited, a single apron may be needed for a whole session seeing flu patients. Eye protection 4.13 Eye protection will be needed in accordance with existing practice, when undertaking procedures where there is a risk of splashing on the face. The ocular route of inoculation is not regarded as a major route of transmission for normal human influenza viruses, but is nevertheless biologically plausible. Aerosol generating procedures 4.14 Refer to guidance notes to complete this section Cleaning and disinfection 4.15 Although the influenza virus can survive on hard surfaces for several hours, it is readily destroyed by cleaning with standard detergents and disinfectants. The practice will have an enhanced cleaning programme throughout all clinical areas, at least daily or after a session when a flu patient has been seen before the next non-flu patient. Frequently touched surfaces such as door knobs will need cleaning more often, and freshly prepared neutral detergent and hot water should be used for this purpose. 4.16 An example of a cleaning schedule for use during the pandemic is shown at Appendix C. 4.17 Common diagnostic instruments, such as stethoscopes, should be cleaned frequently, and always between use on flu and non-flu patients. 4.18 Soft furnishings will be difficult to clean, and should be removed and stored, together with books, magazines and toys, until the pandemic is over. Carpets are not likely to present a transmission risk. 4.19 No special procedures will be needed for clinical waste. Gloves should be used for handling waste, with hands washed after gloves are removed as usual. 4.20 No special arrangements are needed for patient care equipment, other than more scrupulous care than usual to clean and if appropriate decontaminate between patients. 5. BUSINESS CONTINUITY Business Continuity Plan 5.1 The business continuity plan for the practice is derived from the Service Continuity Planning Framework produced by the Royal College of General Practitioners and the British Medical Associations General Practitioners Committee. The business continuity plan is detailed at Appendix D. 5.2 At UK Alert Level 1, the (enter postholder detail).. will ensure there are adequate stocks of essential items in the practice and that assurances of continued supply are obtained from the contractors and companies who supply the practice. QOF arrangements 5.3 The Department of Health has stated that GP Practices will not be financially disadvantaged if, because of the workload generated by dealing with an influenza pandemic, there is delay or other temporary failure to achieve QOF targets. 5.4 At UK Alert Level 1, arrangements will be made by the practice to bring forward or postpone clinics etc and to adjust repeat prescription issue with the intention of freeing up as much time as possible during the peak weeks of the pandemic. The (enter postholder detail).. will be responsible for ensuring patients are advised of the changes and the reasons for it, and for ensuring the changes are documented adequately to provide evidence in support of subsequent QOF claims, in line with guidance expected to be issued by Somerset Primary Care Trust. APPENDIX A Patient and Staff Communications material APPENDIX B Influenza Pandemic segregation plan Cleaning and disinfection Cleaning schedule Surfaces to be cleanedFrequencyMethodCleaning agentSpecial instructionsCleaned byFloorsWallsCeilingsDoorsTablesWork surfacesDiagnostic instrumentsSanitary accommodation  APPENDIX D Influenza Pandemic Business Continuity Plan Introduction There have been influenza pandemics around the world in the past with the last occurring in 1967. Pandemics have the potential to disrupt both the service provision by the practice in a variety of ways and although we cannot specify precise details of how it would be managed in advance of the actual disease presenting itself there are certain situations that are worthy of consideration at that point. This Appendix to our plan looks at what the threats may consist of and offers some strategies it is likely that the practice will need to be flexible and innovative in its approach, the headings listed below will need to be assessed prior to a pandemic and at a regular basis during a pandemic by a practice management team perhaps in collaboration with other neighbouring practices and/or PCT. Threats Transmission of Flu to Staff and Doctors Absenteeism and Extended duration Increased work load Family commitments Wider Health community needs Loss of Utilities Transmission of Flu to Staff and Doctors There is a risk of transmission of Flu from patients to Doctors and Staff, as there is from anyone that we meet who is unwell, eventually at least 75% of the population will have been exposed to the virus. Due to the nature of our work we are likely to be exposed to large quantities of virus. Spread of the virus is likely to be due to airborne particles and expelled particles that have landed on surfaces with which we have contact. Spread of the disease within the practice can be reduced by infection control methods, though it is unlikely to be a complete process Plans will change as the risk and workloads alter but will include Segregation of Flu patients using different waiting areas and dedicated consulting rooms Segregation of doctors and staff managing flu patients, one doctor and receptionist dedicated to flu patients, running an open house surgery Wearing of appropriate Personal Protection Equipment by staff dealing with Flu patients according to guidance at time Prophylactic antiviral medication may be appropriate for some staff and will follow guidance issued at the time. Staff who become sick will not be expected to attend work Use of recovered (immune) staff to deal with flu patients Absenteeism and Extended duration It is anticipated that the first wave of the pandemic will last 3- 4 months with a peak of activity lasting at least 6 weeks. It is also likely that absenteeism within health workers will be in the region of 25% at anyone time and possibly higher. Plans to deal with this will vary through the course of the pandemic but it is useful to consider the following Cancellation of outside activities (Meetings, teaching etc) Define minimum safe staffing levels Suspension of Chronic Disease Management Suspension of New routine referrals Increase repeat medication requests to 90 days for most drugs Suspension of Minor Surgery, Coil fittings Emergency Only open surgeries Team working with neighbouring practices Identify retired or non practicing colleagues who might be utilised We would not expect planned holidays to be altered as breaks for hard working staff are accepted as necessary during an extended incident. Alteration of Workload This may be altered by patient concerns and behaviour, need for antiviral therapy, capacity issues within secondary care. It is anticipated that the practice will need to alter some of its work patterns to provide extra capacity. See list above Family commitments It is recognised that General Practice staff and Doctors have a high level of dedication to their patients, but that it is sometimes necessary to put family in front of service to others. It is likely that at times during a pandemic there may be issues for members of staff in dealing with sick family members or where normal child care arrangements cause problems (Schools closed etc.). We will try to support and accommodate this where possible by flexible shift working, crche/babysitting facilities at work, and if unavoidable unscheduled leave of absence. We will expect that this supportive approach from the practice will foster a similar approach from its staff and doctors.  SHAPE \* MERGEFORMAT  Wider Health Community Needs It is possible that we will be asked to contribute towards support of the wider health communitys needs. It is difficult to be precise as to what these may be but may include Support of neighbouring practices and single handed practice Support of Out of Hours service Mass treatment distribution centres Mass vaccination strategies Support and advice to Pandemic Management teams These will be considered according to the threat and available man power but it may be necessary to adapt staffing levels within the practice to accommodate this important role. Loss of Utilities It is not expected that there will be extended periods of power loss during a pandemic, but fuel and food supplies may be difficult at times. This may need special arrangements to be made such as ID passes.     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