Managing pandemic influenza in general practice


A guide for preparation, response and recovery

6.3 Infection prevention and control

☰ Table of contents


General practices can reduce the risk or prevent the transmission of infectious diseases by embedding infection control measures in everyday practice. All GPs, clinical staff and non-clinical staff should have a good understanding of infection control principles.


6.3.1 Standard precautions


Standard precautions are applied to the care of all patients. Hand hygiene is a key standard precaution.

Standard precautions should be used routinely and consistently to achieve a basic level of infection prevention and control when staff are likely to be in contact with:

  • blood
  • other body fluids, secretions or excretions, except sweat (eg. urine, faeces)
  • non-intact skin
  • mucous membranes.

In preparing for a pandemic, practices may wish to scale up the use of standard precautions. For example, by providing conveniently located dispensers of alcohol-based hand rub – near each workstation, in patient waiting areas, in consulting and treatment rooms, including allied health rooms, and in reception and staff meeting rooms.

Additionally, practices may prohibit staff from wearing ties.

Refer to the RACGP’s Infection prevention and control standards (5th edition).

 

6.3.2 Transmission-based precautions


Transmission-based precautions (previously known as additional precautions) are used where patients have suspected or known infectious conditions.

To minimise the spread of influenza, contact, droplet and airborne precautions (transmission-based precautions) are used in addition to standard precautions:

  • Contact precautions are used to prevent both direct and indirect contact transmission. Contact precautions involve the use of gloves, gowns and distancing. Gloves need to be worn for all manual contact with patients, associated equipment and the immediate environment. A water-impermeable apron or gown needs to be worn if clothing could be in substantial contact with the patient or their immediate environment.
  • Droplet precautions are used to minimise transmission of droplets generated by coughing, sneezing and talking. Droplet precautions involve the use of surgical masks (worn by staff and patients), protective eyewear (goggles or face shield) and distancing. Patients should be asked to observe respiratory (cough) hygiene.
  • Airborne precautions should be used to minimise transmission of micro-organisms suspended in the air. Airborne precautions involve the use of P2/N95 masks, protective eyewear (goggles or face shield) and minimising exposure time to other patients (scheduling influenza patients at the end of the day, distancing, home visits). Where possible, avoid aerosoling procedures such as nebulisers. Additionally, preference should be given to the use of spacers for the delivery of salbutamol when needed.

Refer to the RACGP’s Infection prevention and control standards (5th edition).

 

6.3.3 Implementing infection prevention and control measures


Prevention of infection and disease transmission relies on the implementation of effective infection prevention and control measures. These measures can be viewed as three separate components: individual measures, organisational and environmental measures and PPE.

Control measures

The implementation of all three components will help to reduce the risk of practice staff and patients being exposed to the influenza virus; an individual component will not be effective if undertaken/used in isolation (eg. PPE only).

Reducing  the risks
Preparing for the management of outbreaks of respiratory (and other) infections should focus on good governance with planned, practised and habitual infection prevention and control measures, and a stepwise response according to the extent and severity of the outbreak.23

Practice staff should be familiar with infection prevention and control principles and how to appropriately scale usual measures in response to an outbreak of disease.

 

6.3.4 Individual-based precautions


Staff education on preventing the spread of infection

All members of the practice team need to be educated about their role in preventing the spread of infection.

Education includes the teaching of the principles of infection prevention and control, including the various infectious agents, their modes of transmission, appropriate work practices for infection prevention and control and what personal protection is required and when to use it.

All staff need to demonstrate competency (appropriate to their role) in:

  • identifying the signs and symptoms of influenza
  • hand-hygiene procedures
  • standard precautions
  • transmission-based precautions
  • managing blood and body fluid spills
  • managing blood or body fluid exposure
  • waste management
  • principles of environmental cleaning and reprocessing medical equipment
  • notification and referral pathways to appropriate health authorities
  • where to find information on other aspects of infection control and pandemic protocols in the practice.

Understanding why precautions (such as masks) are used and the factors that have an impact on their effectiveness is critical to ensuring that staff are adequately protected, comfortable and can perform their jobs.14

During a pandemic, roles within the practice team may change. Some staff will need to multitask and take on additional responsibilities. This may mean additional training in infection prevention and control practices.

Refer to online hand-hygiene course.

Patient education on preventing the spread of infection

Patient education and engagement is vital for effective pandemic management. The public needs to be empowered to take responsibility for their own health.24 Educating patients on the issues around pandemics increases awareness of risks, engenders cooperation, facilitates co-ownership and commitment, and assists in the prevention of transmission and complications.

Patients should be educated about infection prevention and control strategies (eg. cough etiquette, hand hygiene) and be encouraged to report any potential infectious disease to practice staff as soon as possible. Research shows that providing information about influenza prevention at the community level can help reduce severe and complicated cases of influenza requiring hospitalisation.25

During flu season and/or the standby stage, it is recommended that practices display posters to remind patients of the importance of handwashing and cough etiquette.

Seasonal vaccinations

The WHO position on seasonal influenza vaccines is that they are ‘safe and efficacious and have the potential to prevent significant annual morbidity and mortality.’31 The NHMRC’s Immunisation Handbook (10th edition), recommends annual influenza vaccinations for healthcare professionals and patients.32 General practices should encourage influenza vaccination for both staff and patients as an effective measure to reduce transmission of influenza.

Seasonal influenza vaccination uptake is low among healthcare workers. After the 2009 H1N1 pandemic, only Mexico experienced a significant increase in uptake of season influenza vaccination.33 The most common reasons for healthcare staff rejecting vaccination are fear of adverse events, doubt regarding efficacy, not feeling as belonging to a high-risk group and believing that influenza is not a serious illness. The main predictor of vaccine uptake is previous influenza vaccination.34 Strategies to improve vaccination rates include in-practice vaccination programs for staff, use of practice ‘champions’, electronic databases to track vaccinations and marketing campaigns.35,36

 

6.3.5 Organisational and environmental measures


Risk assessment and management

Risk identification and management is a fundamental aspect of a high-quality, resilient and sustainable practice. This applies not only to infection prevention and control but right across all aspects of the practice.

Planning for a pandemic needs to take into account the risk factors regarding the disease (eg. transmission, virulence, morbidity and mortality) and the vulnerabilities particular to each practice (eg. size of the practice team, patient cohorts, access to additional resources, patient flow within the practice, financial implications). Together these provide the context of the risk.

The disease-specific factors will not be known until the time of the outbreak (and may change rapidly during the outbreak). Identification of potential areas of risk with practice systems and processes can be done during the preparedness phase and then reviewed in the event of a pandemic threat.

Some sources of risk are common; for example, inadequate hand hygiene, poor respiratory (cough) etiquette, lack of effective triage protocols and high workload with stress and fatigue.

During the preparedness phase, it is recommended that the pandemic coordinator undertake an assessment of all the possible risks to the practice and identify appropriate strategies to manage them. Once risks are identified, they are analysed for their magnitude of impact and their likelihood of occurring. There may be some situations where doctors and other health professionals have different opinions about risk and therefore the appropriate approach to that risk.

Discussions should occur before an event so that a consistent approach can be decided upon. Developing policies based on evidence based guidelines can help address difference of opinion regarding risk.

Risks are then evaluated and prioritised – which risks need to be actively managed, why and how; and which risks will be ‘tolerated’ (ie. what risk a practice believes is minimal).

Having taken account of all the relevant factors, including practical and financial implications, it is important to act on identified priority risks. Start with the potential solutions/safeguards that are easy to do and have high impact (eg. placing alcohol-based hand rubs in all patient care areas to improve hand hygiene and reduce cross-infection). Then give attention to those that are hard to do but have high impact.

All protocols and procedures to manage risk should be documented, monitored and regularly reviewed.

Execution of mini-drills could be conducted (depending on time and manpower availability) to investigate the practicalities and logistical barriers of some of the actions proposed. Consider scenarios of pandemics with various severities and formulate some options and innovative solutions for handling these scenarios.

Refer to the RACGP’s Infection prevention and control standards (5th edition) for further information regarding risk assessment and management.

Triage

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 disease that fit with the current ‘case definition’ of the pandemic in patients presenting to or calling the practice, and respond appropriately.

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

Document questions to be asked at reception and the expected staff responses required. All staff will need training in triage protocols. Display triage questions in an easily accessible algorithm at reception.

Leaflets and notices in the waiting room, posts on the practice website or messages while callers are on hold can provide patients with information that will further support the appropriateness of triage.

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.

Separating patients who are well from patients who are ill

Distance barriers are effective in preventing disease transmission.20 The practice will need to explore some patient flow options to reduce contact between patients with influenza-like symptoms and those without. Examples include creating a mini–influenza clinic (eg. a designated waiting area with a designated GP), assigning the ‘worried well’ to a clinic nurse26 and using areas such as the car park for patient triage. Practices may also consider using a dedicated consultation room to treat/manage patients with influenza-like symptoms.

Staff will need to know the roles of 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 1 metre from patients without influenza, or 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. Influenza patients 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.27 General practices may need to liaise with local schools and childcare facilities.

Infection prevention and control outside the practice

Practices need to ensure that provisions for these precautions are made for patients seen offsite (ie. home visits, visits to residential aged care facilities). Home visit kits must be appropriately stocked to manage patient needs and staff protection (eg. clinical waste disposal equipment). 

 

6.3.6 Personal protective equipment


PPE is a first line of defence against the spread of viral infection and an integral component of quality healthcare.14,28

Lessons learned from past events indicate that during a pandemic there is an increased demand for key supplies, often resulting in a shortage of essential equipment. Where possible, practices should have appropriate stocks of clinical and non-clinical supplies to ensure continued provision of essential patient services and staff safety in the event of a pandemic.

The SARS outbreak illustrated the critical importance of basic infection control precautions in healthcare facilities, with transmission of disease frequently associated with noncompliance with standard precautions.28

However, the 2009 H1N1 influenza pandemic highlighted uncertainty in the strength of evidence supporting the type of PPE, particularly face masks and respirators, in different settings. As new information becomes available this kit and related resources will be updated. Notwithstanding this uncertainty, subsequent studies do suggest that masks are likely to play a vital role in mitigating pandemic influenza spread.29

General principles for PPE selection and use are that PPE should be:14

  • appropriate to the occupational risk
  • acceptable and usable by healthcare personnel in their daily tasks
  • practical regarding issues of cost, time and training to use.

From a patient perspective, approaching someone wearing PPE can be very confronting. The use of PPE should aim to minimise negative interaction with or effects on patients and their families.14

What PPE is required?

PPE is not a substitute for hand hygiene and cough etiquette and should be used in conjunction with individual and organisational and environmental measures.

The PPE appropriate for a pandemic includes:

  • gloves
  • disposable plastic aprons
  • surgical masks
  • P2/N95 masks (respirators)
  • goggles/glasses
  • face shields
  • gowns.

Disposable PPE should be used because the influenza virus can remain infectious on surfaces for long periods of time.

How much PPE should a general practice have in stock?

Practices are responsible for sourcing and providing PPE for staff and patients within the practice. While there is a national medical stockpile of PPE held by the Australian governments (national, state and territory), supplies are limited and access to the stockpiles should not be assumed.

Practices are encouraged to maintain a supply of hand-hygiene products, tissues and PPE for staff for the duration of a pandemic wave (approximately 4 weeks).

Practices need to consider if they have sufficient storage space to house PPE. If necessary, they may consider relying on existing networks (eg. local pharmacy) to store supplies until required.

Stocks need scheduled checks, as some items are perishable. For example P2/N95 masks have perishable elastic and an expiry period of 5–7 years.

Who should wear PPE?

Use of PPE depends on the risk of transmission of infection.

During normal practice, PPE is typically only used by staff who are in close contact with patients or potentially infectious/dangerous materials. However, during a pandemic, practices should plan to have PPE available for all practice staff.30

What about PPE for patients?

The primary tools for reducing transmission between patients are:

  • distancing (based on effective triage)
  • hand hygiene
  • respiratory hygiene.

Practices could consider providing surgical masks to patients with an influenza-like illness.12 Patients wearing PPE must also be advised on how to remove and dispose of PPE safely.

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