Pandemic Influenza: Strengthening the frontline Dr Nick Phin Pandemic Influenza Offcie HPA Centre fo

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Pandemic InfluenzaStrengthening the
frontlineDr Nick PhinPandemic Influenza
OffcieHPA Centre for InfectionsLondon

• June 2008

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Objectives of the presentation

• Share the outcomes of a simulation exercise to
  quantify personal protective equipment usage
  during a pandemic
• Explore the use of simulation to test operational
  assumptions and provide an objective assessment
  of staff preparedness

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Rationale

• The practicalities and feasibility of the
  national infection control guidance have not been
  tested
• There are no normative values to estimate likely
  usage of personal protective equipment
• Test assumptions about staff knowledge and
  awareness of infection control procedures
• Develop a model for sharing learning experiences
  in a cost effective manner

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Exercise

• For a 24 hour period all staff on an acute
  medical ward adopted the infection control
  procedures described in the UK pandemic influenza
  infection control guidance
• Practice was observed throughout the 24 hour
  period by teams of infection control nurses drawn
  from 17 volunteers
• Usage of PPE was recorded
• Staff attitudes to wearing PPE were observed

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Preparation (1)

• The hospital ethics committee were consulted and
  they agreed the exercise did not need ethical
  approval
• Key managers and clinicians were involved in the
  planning meetings
• All staff in the hospital were made aware of the
  exercise
• Patients and their visitors were informed and had
  an opportunity to discuss the exercise beforehand

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Preparation (2)

• Staff on the ward were briefed and given one to
  one training on the infection control procedures,
  how to don and wear PPE and were fit tested for
  FFP3 respirators
• 17 infection control nurses from various
  hospitals and community settings across the
  locality were rostered to observe and monitor
  practice
• Reactive press briefs were prepared

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Setting

• 29 bedded acute respiratory and gastro-intestinal
  ward
• Consists of 2 negative pressure rooms, 1 side
  room, 2 four bedded bays and 3 six bedded bays
• 14 trained nurses, 5 healthcare assistants and 4
  domestic staff

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Current Guidance

• Guidance for Pandemic Influenza
• Infection Control in Hospital and Primary Care
  Settings
• Department of Health, England
• Health Protection Agency
• November 2007

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Infection control principles

• In the UK there is limited availability of single
  occupancy rooms patients are typically managed
  in open bays with 4-6 beds
• Important principle in UK guidance is the
  cohorting of people with influenza-like illness
  during a pandemic
• Mainstay of infection control is around standard
  precautions and droplet precautions

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Infection control principles

• Fluid repellent surgical masks are advocated in
  most patient contact situations
• High level respiratory precautions are reserved
  for aerosol generating procedures where FFP3
  respirators are used
• FFP3 respirators are closely equivalent to US N99

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Personal protective equipment for care of
patients with suspected/confirmed pandemic
influenza

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Results - Headlines

• Mismatch between expected usage and actual usage
• Staff still uncertain of basic infection control
  guidance
• Even with extra staff ward unable to keep to
  usual schedule
• Current operational assumptions too simplistic

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PPE usage over 24 hour period
Unadjusted figures
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Pandemic v normal usage
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Comparison between the simulation and WHO
estimates
Usage over seven days based on 29 patients
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Clinical waste

• During the 24 hour period 18 sacks (48 litres per
  sac) of clinical waste were generated compared
  to four or five. Equates to over 100,000,000
  litres nationally
• Implications for waste removal and disposal
• Is it really clinical waste?

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Operational issues

• Recognition that the standard of care will be
  different
• Large amounts of traffic over 115 different
  hospital personnel (excluding ward staff) visited
  the ward during the 24 hour period
• Need to consider cohorting groups of patients
  with similar needs so as to streamline the
  delivery of care eg grouping all those needing
  nebulisers

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Operational issues

• Will probably have to adopt a task based approach
  to the provision of care
• Communications were more difficult and patients
  and staff alike had problems with peoples
  identities

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Impact on normal working practices
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Staff issues
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Staff Issues
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Was it worthwhile?

• Useful norms for planning purposes and more
  robust than armchair planning
• Infection control measures are labour intensive
• By observing people over a period thye forgot you
  were there and you could get a real assessment of
  practice this unfortunatly highlighted the need
  for on going infection control training and the
  need to inculcate this into everyday practice

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Was it worthwhile? (2)

• Highlighted that the infection control measures
  could not simply be superimposed on usual
  practice a rethink of practice will be required
• Both the ward staff and the participating
  infection control nurses indicated that they had
  found it very useful
• The involvement of staff from other organisations
  was a cost effective way of sharing the learning
  from the exercise

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Was it worthwhile? (3)

• Disposal and storage of PPE will be a issue
• Relatively inexpensive tangible cost in the
  region of 3,000
• Highlighted the potential danger of using norms
  from different health systems
• PPE is not issue free and without consequence
• Still a way to go!!

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Lessons learnt

• Medical staff will be a big problem
• Careful planning and need to involve senior
  clinical and managerial staff
• Need to communicate and inform all staff across
  the hospital about the event and be prepared to
  respond to press interest
• Takes more time than you think
• Asking for small amounts of monay is harder than
  asking for large amounts!
• Need a champion

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Acknowledgements

• Dr Alison J Rylands, Wirral University Teaching
  Hospital NHS Foundation Trust, Arrowe Park
  Hospital, Upton, Merseyside,
• Joseph Allan, Wirral University Teaching Hospital
  NHS Foundation Trust, Arrowe Park Hospital,
  Upton, Merseyside,
• Carmel Edwards, Wirral University Teaching
  Hospital NHS Foundation Trust, Arrowe Park
  Hospital, Upton, Merseyside,
• Joanne E Enstone, Health Protection Agency,
  University of Nottingham
• Professor Jonathan S Nguyen-Van-Tam, Health
  Protection Agency, University of Nottingham

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Acknowledgements

• We wish to thank all the staff of Ward 37, Arrowe
  Park Hospital for their commitment,
  professionalism and enthusiasm both before and
  during the exercise
• The management of Wirral University Teaching
  Hospital NHS Foundation Trust for supporting this
  piece of work
• Gavin Flatt, trainee public health analyst for
  collating and tabulating the staff
  questionnaires
• All of the infection control nurses who
  participated in this exercise
• The study was supported by the Department of
  Health, England who provided funding for the
  costs of the extra PPE expended in the exercise.