Infection prevention and control

In the event of a pandemic, the priorities include staff staying well, prevention of cross-infection of patients and appropriate management of patients with pandemic influenza. To reduce risk:

• do not allocate febrile patients to staff at increased risk
• re-organise the clinic schedule to minimise cross-infection with minimal disruption of usual services⁴⁵
• consider delaying non-urgent and routine non-essential consultations during a pandemic (eg Pap smears).⁴⁶

The importance of infection prevention and control procedures is critical during a pandemic. GPs and clinical staff should take a proactive approach and reinforce the importance of infection prevention and control measures during a pandemic.²⁹

Review your current infection prevention and control plans in light of available pandemic information. Update or adapt protocols on:

• hand hygiene (eg increase the number of alcohol-based hand sanitiser dispensers)
• use of PPE for staff and patients
• practice cleaning, removal of clutter and non-cleanable items such as waiting room toys and waste disposal (use no-touch waste dispensers)
• the use of quarantine and social isolation (eg increasing home visits or practice modification to create separate waiting areas for influenza and non-influenza patients)
• assigning personnel to different tasks and patients (eg one GP does not see any influenza patients, a practice nurse to see the ‘worried well’, one GP to do influenza home visits)
• throat swabbing
• vaccines (depending on availability, distribution and immunisation strategies).

Ensure that these protocols are clear, simple, easy to implement and are scaled appropriately to the level of risk. Display alert and education materials for staff and patients.

Febrile staff with respiratory symptoms should not come to work until considered non-infectious (based on current information about the influenza strain).

General practices may choose to encourage seasonal influenza vaccination of staff.²⁹

Pneumococcal pneumonia is likely to be a significant complication of pandemic influenza. Practices should identify at-risk patients and offer pneumococcal vaccination.¹¹

Check regularly with the relevant state or territory health department about pandemic vaccination availability and distribution and immunisation strategies.

Practices will need to check antiviral protocols with the state or territory health department.¹¹ In some cases there may be targeted antiviral prophylaxis for contacts and frontline health workers.

During a pandemic, vigilance in detection and immediate reporting of suspected cases of pandemic influenza is critical. A person is classified a ‘contact’ if they have been in close proximity with a person who has been diagnosed with pandemic influenza and therefore has the potential of becoming infected. The exact definition of a contact depends on the nature of the illness and the phase of the pandemic.

It is important to be aware of the changes of ‘case definitions’ as a pandemic develops. The case definitions used by state and territory health departments will change at different phases of the pandemic, as knowledge about the disease increases.

Practice staff may be required to supply names and contact details of patients who have been in close contact with a patient with suspected pandemic influenza to health authorities. Patient confidentiality and privacy is a core element of the management of patient health information. However, during a pandemic, confidentiality and privacy may be overridden by public health concerns and mandatory reporting requirements.
 

Early recognition of patients with suspected influenza will allow for appropriate patient management and reduced risk of transmission. All staff need to be able to recognise the symptoms and signs of potentially infectious diseases. This should include matching patients who present to or call the practice to the current ‘case definition’ of the pandemic and responding appropriately.

Consider developing a checklist for patients and staff to identify potential cases of influenza.

This may include questions commonly asked at reception and examples of expected staff responses. All staff will need training in triage protocols. Ensure triage questions are easily accessible at the reception desk.

Leaflets and notices in the waiting room, posts on the practice website or messages while callers are on hold are additional strategies for providing patients with information to support the triage process.

During a pandemic, health authorities will provide a more specific case definition. Definitions used by health authorities to identify cases of pandemic influenza may change at different phases of a pandemic, as knowledge of the disease increases. General practices need to maintain good communication pathways with state and territory health authorities to ensure timely notification of any changes to case definition or clinical management.

Distance barriers are effective in preventing disease transmission.²⁰ Exploring some patient flow options to reduce contact between patients with influenza-like symptoms and those without is useful. Examples include creating a mini-influenza clinic (eg a designated waiting area and GP), assigning a clinic nurse to those who are considered ‘worried well’³⁶ and using areas such as the car park for patient triage. Practices may also have a dedicated consultation room to treat/manage patients with influenza-like symptoms. It is important to understand the differences between isolation and quarantine.

• Isolation is used to physically separate symptomatic patients with an infectious disease from those who are healthy during the infectious period. In the practice, isolation includes distancing (eg seating patients with influenza at least one metre away from patients without influenza, ideally in another area or consultation room of the practice). Isolation could be extended to all patients with an influenza-like illness being seen at a separate facility, such as a flu clinic.
• Quarantine is used to physically separate and restrict movement of asymptomatic persons who have potentially been exposed to an infectious disease to see if they become ill. People with influenza may be infectious before they become ill themselves. People in quarantine may be asked to monitor their temperature. They will need to know how to use a thermometer, how often to take their temperature and what to do if they develop a fever (ie temperature ≥ 38 °C). Quarantining of patients is not a mandatory requirement and therefore not enforceable. Practices should advise/recommend influenza patients to stay at home and limit contact with other people.

It may be particularly important to separate age groups. During the H1N1 pandemic, while adults were responsible for seeding the infection in communities, children frequently drove community outbreaks.⁴⁷ General practices may need to liaise with local schools and childcare facilities.