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Influx Plan - (Infectious Persons)

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

POLICY:
In the event of a real or potential 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.

DEFINITIONS:
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.

I.Implement the Emergency Operations Plan
The Command Center and Incident Commander will determine if the event exceeds the ongoing capacity of the hospital and requiring the activation of community resources. Infection Control and other existing policies will be followed. Consultation with the Infection Control Professional and Infection Control Physician as part of the Incident Command System will be followed. The Fast Command can be accessed via the intranet.  See VII below).

II.Community Resources:
If community resources are necessary, the Command Center will contact the Chatham County Health Department (919-742-5641) and/or Chatham County Emergency Management.  Decision making will then be coordinated with the public health department and other disaster agencies. Additional advice can be obtained from Hospital Epidemiology at UNC Hospitals (919-966-4131) and the Chatham County Health Department.

III.CRITICAL PATIENT CARE ISSUES:
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 Chatham County 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
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.

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

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

I.   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 or NC Department of Public Health recommendations.  If airborne isolation is required, conduct vertifications 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   , ICU 2, Med/Surg 1110.

2.  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 N95 mask is indicated, staff must have completed a successful fit-test annually, prior to donning the mask.

3.  The Infection Control Nurse will make recommendations for the disposal of linens and medical waste based upon guidance from local and state health departments.

J.  Employee Health Services
The Unit Directors 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.

K.  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.  Sighs will be posted at all entrances to the hospital regarding visitor restrictions.  Non-compliant visitors will be reported to the local public health department.

L.  Community Communications and Warning
In the event the Public Health Department issues a community warning NOT to come to the hospital unless absolutely necessary. FAST COMMAND will be utilized to communicate the warning to the public.  The Public Information Officer will oversee public communication warnings.

M.  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.

IV.Type of Infectious Disease/Mode of Transmission:  Determination of what type of infectious disease and the mode of transmission.  Follow the Isolation Precautions Policy in the Infection Control/Employee Health Manual including signage. Consult the Pandemic Influenza Plan and SARS plan if applicable. If more than Standard Precautions are needed, make a decision on the following:

a. Are Airborne Infection Isolation Rooms (AIIR) needed:  If yes, there are 4 negative pressure isolation or AIIR in the hospital: Room 6 in the Emergency Department, Room 1110 in the Medical/Surgical Department, Room 2 in the Intensive Care Unit, and Room 6 in the Post Anesthesia Care Unit.  If more than the capacity of those areas, then an outside shelter in conjunction with community resources will be required. Maintenance will be responsible for ensuring that AIIRs are functioning properly.  Nursing staff must perform a tissue test prior to placing a patient in an AIIR and at least daily thereafter.

If all AIIR are in use, maintenance will investigate whether non-AIIR rooms can be modified to achieve appropriate airflow direction and/or air exchanges.

If a patient leaves the AIIR, the door must be kept closed with the sign still on display for a minimum of 30 minutes prior to anyone entering without respiratory protection (N-95 mask or PAPR).

b. If Contact or Droplet Precautions are needed: The facility can accommodate 21 patients on the Medical/Surgical Unit and 4 in the ICU.  Two additional beds are available in a semi-private room on the Medical/Surgical Unit. Additional beds may be available in the Pre-Op and PACU areas; consult with the Incident Commander and OR Director for availability.

NOTIFICATION OF POTENTIAL EPIDEMICS OR NEW INFECTIONS
The Infection Control Nurse 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 has 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.

RESPONSIBILITY:
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.

V.Bed Availability:
This will be determined within the context of the EOP, the infectious disease and mode of transmission.  The Infection Control Physician and the Infection Control Professional should be consulted.  Refer to Critical Bed Status Policy.

VI.Signage:
Signs in appropriate languages may be required outside the hospital and/or the Emergency Department so that patients with event specific symptoms identify themselves to the triage nurse or intake staff.

VII.Communication and Triage:
Clinicians, triage and appropriate staff, will be regularly updated via email, memoranda, or other methods on the status of the outbreak of the infectious disease. Triage staff will be notified of how to assess for signs and symptoms of the infectious disease. A sample of a triage form is attached in Appendix A.

VIII.Supplies:
Follow the EOP. Determine the inventory of personal protective equipment and hand hygiene supplies and begin ordering additional supplies.  Follow the Tuberculosis Control Plan recommendations for the use of N-95 respirators if inventory is limited.  Additional supplies may be obtained through the Strategic National Stockpile (SNS) if conditions are warranted.  This is generally done through communication with Chatham County Emergency Management and the Chatham County Health Department.

IX.Staffing:
Follow the EOP and the Infection Control/Employee Health Manual Policies.  Consult with the Infection Control/Employee Health nurse on the immunity of the employee, if applicable, and make assignments accordingly.  Hospital volunteers are included in the Employee Health Plan and may be considered as a resource.

X.Medications:
Follow the EOP and the Infection Control/Employee Health Manual Policies.  Policies are in place for recommendations of prophylaxis and vaccination.  Consult with Pharmacy on availability and necessity of obtaining additional medications.   Additional supplies may be obtained through the Strategic National Stockpile (SNS) if conditions are warranted.  This is generally done through communication with Chatham County Emergency Management and the Chatham County Health Department.

XI.Environmental Disinfection:
Current policies will be followed for environmental cleaning.  These guidelines may require alteration depending on the pathogen of concern and will revised at the discretion of the Infection Control Department.

XII.Additional Policies to Consult (beyond the EOP):

Emergency Management Manual:

a. Disaster Plans; Internal and / or External
b. Bioterrorism Plan

Infection Control Manual:

a.Highly Communicable Respiratory Diseases Plans: Pandemic Influenza Plan and SARS Plan.
b.Employee Health Program Policy
c.Exposure Control Plan (Bloodborne Pathogens)
d.Isolation Precautions Plan
e.Hand Hygiene Policy
f.Guidelines for Personnel with Infectious Disease Policy
g.Tuberculosis Control Plan
h.Notification to Other Agencies Policy
i.Pregnant Employee Precautions
j.Reportable Communicable Disease Policy

APPENDIX A - Syndromic Surveillance Assessment/ Triage Form

US Patent Numbers 7,720,998 B2, 7,836,207