Stony BrookUniversityMedicalCenter

Pandemic Flu Response Plan

Emergency Management

Policy & Procedure Manual

Stony BrookUniversityMedicalCenter

Pandemic Flu Response Plan

Emergency Management

Policy & Procedure Manual

I. Introduction………………………………………………………………………...1

II. Activation…………………………………………………………………………...3

III. Notification…………………………………………………………………………4

IV. Response Plan Table………..………………………………………………………5

Phases 1-3: Inter- Pandemic Period……..…….………………………………...5

Phases 4-5: Pandemic alert……..……………………………………………….8

Phase 6 Level 1: Onset of pandemic outside of North America…...……………….10

Phase 6 Level 2: Outbreaks of novel influenza in North America…….………...... 11

Phase 6 Level 3: First case of novel influenza in SuffolkCounty….……………..…11

Phase 6 Level 4: Epidemic level of novel influenza in SuffolkCounty….…………..13

Phase 6 Level 5: End of first pandemic wave in SuffolkCounty…….…………….. 14

Phase 6 Level 6: Second wave of pandemic in SuffolkCounty……………...... …15

Postpandemic Period………………………………………………………….. 15

V. Termination……………………………………………………………………….17

VI. References……...……………………………………………………………..….18

VII. Appendices.…………………...…………………………………………………..19

A. Pandemic Influenza Information ……………………………………………20

B. Facility Access Plan …………………………………………………………22

C: Antiviral and Pharmacy Information ………………………………………24

D: Surveillance Plan ……………………………………………………………25

E: Nasopharyngeal Specimen collection ………………………………………26

F: Case Criteria, Assessment Tool, Guide to Clinical Assessment ……………27

G: Staff Screening Protocols ………………………………………………….32

H: Ethical Considerations ……………………………………………………..34

I: Recommended Supplies ……………………………………………………35

J. Surge Capacity ………………………………………………………………37

K. Staff Rest and Recuperation ...... 41

L. List of Negative Pressure Rooms …………………………………………..43
Introduction

StonyBrookUniversity was founded in 1957 as one of the four State University of New York’s four University Centers.More than 1,900 faculty teach a total of 22,527 students, including undergraduates. StonyBrookUniversityMedicalCenter is the only tertiary-care center in SuffolkCounty, and serves as a regional center for advanced patient care, education, research, and community service for SuffolkCounty’s nearly 1.4 million residents. SBUMC is a designated Regional Level 1 Trauma Center, the only certified Burn Unit in SuffolkCounty, and SuffolkCounty’sRegionalResourceCenter for Emergency Management.

Most employees of StonyBrookUniversityMedicalCenter, depending on their positions, are represented by public employee unions. These unions negotiate with the State to establish contracts, which define the specific terms and conditions of employment for the members of each bargaining unit. Therefore, employment matters involving terms and conditions of employment must comply with the applicable collective bargaining agreements, where appropriate.

Background Information:

An influenza pandemic may occur when a novel, pathogenic, and readily transmissible flu virus emerges to which few people, if any, have immunity. Any vaccine or therapeutic drugs are likely to be delayed and in short supply. Because of these features, pandemic flu is likely to last several months and affect a large percentage of the national and world population, causing major social and economic disruption. The following are the definitions of terms used throughout this document:

Seasonal influenza: Seasonal epidemics of influenza typically occur during the winter months and are caused by mutations (antigenic drift) in surface viral proteins causing changes in influenza viruses that are already in existence among people. These viral protein changes allow influenza viruses to re-infect people repeatedlythrough their lifetime and is the reason the vaccine must be updated each year.

Avian influenza (bird flu): Influenza viruses that infect birds are called "avian influenza viruses." These are type A influenza viruses that are genetically distinguishable from influenza viruses that usually infect people. Avian influenza viruses do not usually infect humans; however, several instances of human infections and outbreaks of avian influenza have been reported since 1997. The avian influenza strain H5N1 currently circulating in parts of the world is poorly transmitted from person to person and is thus not a pandemic strain, but there is great concern that it could mutate to a form which is more transmissible and lead to a pandemic outbreak.

Pandemic influenza: In contrast to drift in seasonal influenza, pandemic influenza arises through a process known as antigenic shift. In this process, the surface viral proteins are not modified, but are replaced by significantly different proteins producing a novel virus. These new proteins are perceived by the immune system as new and most people do not have pre-existing antibody. A pandemic occurs when a new influenza A virus appears or "emerges" in the human population, causes serious illness, and then spreads easily from person to person worldwide

The potential for large-scale morbidity and mortality from pandemic flu makes a comprehensive response plan critical. The purpose of the plan is to determine actions that should be taken to prevent and/or limit the spread of pandemic influenza among patients, staff, volunteers, students or visitors.

The World Health Organization (WHO) has developed a staged plan, based on its surveillance program for responding to a pandemic threat. The key stages of the WHO response are outlined in Table A.

Table A.WHO Pandemic Model

Pandemic Stage /

Phase

/ Definition
Inter-Pandemic Period / 1 / No new influenza virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals. The risk of human infection or disease is considered to be low.
2 / No new influenza virus subtypes have been detected in humans. However, a circulating animal influenza virus subtype poses a substantial risk of human disease
Pandemic Alert Period / 3 / Human infection(s) with a new subtype, but no human-to-human spread, or at most rare instances of spread to a close contact
4 / Small clusters with limited human-to-human transmission but spread is highly localized, suggesting that the virus is not well adapted to humans
5 / Larger cluster(s) but human-to-human spread still localized, suggesting that virus is becoming increasingly better adapted to humans, but may not yet be fully transmissible.
Pandemic Period / 6 / Level 1*: Increased and sustained transmission in general
population. North America not yet affected.
Level 2*: Outbreaks of novel influenza detected in North
America
Level 3*: First case of novel influenza in SuffolkCounty
Level 4*: Epidemic level of influenza in SuffolkCounty
Level 5*: End of first pandemic wave in SuffolkCounty
Level 6*: Second outbreak of disease, caused by the same
novel virus strain, within SuffolkCounty
Postpandemic Period / 7 / Indices of influenza activity have returned to essentially normal inter-pandemic levels and immunity to the new virus subtype is widespread in general population. An intensive phase of recovery and evaluation may be required.

Note: Phase 6 of the WHO pandemic model was subdivided to reflect local conditions.

The WHO Pandemic model has been modified to include reference to disease activity in North America as seen above and applied to the hospital environment. Table B describes this hospital modification.

Table B. Hospital Pandemic Influenza Alert Matrix

What type of transmission is confirmed? / Where are the cases? / Are there cases in the hospital? / Alert Level
None or sporadic cases only / Anywhere in the world / No / Inter-pandemic period
Person-to-person transmission / Anywhere outside North America / No / Pandemic Alert Period
Person-to-person transmission / Anywhere in North America / No / Pandemic Period
Person-to-person transmission / In Hospital / Yes / Pandemic period

The document outlines a plan for responding to various levels of threat posed by pandemic influenza with an approach to stepping up prevention and control activities as the threat increases. Vigilance at all times for syndromes that may represent contagious respiratory infection should be the norm not the exception. A group of people should be maintained who are prepared to actively respond to changing situations by implementing appropriate portions of the plan when indicated. The mechanism to achieve this is the implementation of the Incident Command System.

II. Activation

The Incident Command process will be activated upon declaration of a phase 4 pandemic alert by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC). StonyBrookUniversityMedicalCenterwill be notified by the local and state health department representatives. This occurs through several processes:

a) The New York State Department of Health will activate the Health Provider Network (HPN) and issue an alert (telephone and email) which will be sent to numerous hospital roles i.e. Bioterrorism Coordinator, Chief Executive Officer, Designated Pharmacist, Infection Control practitioners, et B.;

b) fax notification from the New York State Department of Health is received at the Switchboard who then contact the Administrative Supervisor with the information;

c) local health department officials will contact key roles at StonyBrookUniversityMedicalCenter, i.e., Infection Control Practitioners, Emergency Department personnel, Emergency Response Coordinators, and the Administrative Supervisor and;

d) the Suffolk County Department of Fire, Rescue and Emergency Services Office of Emergency Management will also contact key hospital personnel.

The phases of pandemic flu, as defined by the WHO, are shown above in Table A. Identification and declaration of the pandemic phases will take place at the international and national levels. Preparedness and response activities for StonyBrookUniversityMedicalCenter will be organized by pandemic phase.

In response to a Phase 4 alert,StonyBrookUniversityMedicalCenter will active the Incident Command process. The Incident Commander shall appoint the following roles:

Operations Section Chief

Logistic Section Chief

Planning Section Chief

Finance Section Chief

External Agency Liaison

Public Information Officer

Safety Officer

Security Officer

Review of the Pandemic Influenza Plan shall occur. The External Agency Liaison shall become the point of contact for external communications with other agencies regarding Pandemic Influenza. Weekly meetings shall occur to review the latest information, state of preparedness at StonyBrookUniversityMedicalCenter, resource availability and communications with employees and staff.

Others to be included in this alert phase planning group are:

Healthcare Epidemiology/Infection Control

Employee Health

StudentHealth Services

Chief Nursing Officer

Adult and Pediatric Infectious Disease practitioners.

The group requires a 7 day a week availability to respond to a potential outbreak of pandemic influenza.

As the phases of Pandemic alert escalate additional roles shall be added as needed. At Pandemic Phase 6 the following roles shall be assigned:

Incident Commander

Safety Officer (with Infectious Disease Expert Consultants)

Security Officer

External Agency Liaison

Public Information Officer

Medical Director

Logistic Chief

Finance Chief

Planning Chief

Operations Chief

POD Director

III. Notification

StonyBrookUniversityMedicalCentershall receive notification from various sources in a variety of ways. Incident Command will manage the process of activating the Pandemic Influenza Plan. The Incident Commander will call a planning meeting with the above designated roles. After the development of the Incident Action Plan, informational meetings with be held with Senior Hospital Officials. The Chief Executive Officer or designee will confer with the Dean and the President of the University. The External Agency Liaison shall be responsible for the notification of facilities for which the hospital provides back-up services when it will no longer be able to provide such services.

IV. Response Plan Table

Phases 1-3: Inter-Pandemic Period – No new influenza virus subtypes have been detected in humans

Response Component /

Actions

Command and Control

/
  • Administrative, educational and clinical leaders will promote maximum participation of staff, volunteers and students in the influenza vaccine program
  • Administrative/clinical leaders will advise staff, volunteers and students to stay at home if they have a fever and a new cough
  • Assess the availability of equipment and supplies such as ventilators, N-95 respirators, isolation gowns, gloves, surgical masks and begin to stockpile an 8 week on hand supply
  • Make plans for cohort units or areas within the facility where symptomatic and diagnosed patients can be separated from non-affected patients. Review the ability to isolate the ventilation system of the cohort areas.
  • Make plans for the degradation of care and the use of scarce resources, involve the Ethics Committee
  • Make staffing plans, including training of staff to support critical areas (ED, ICU)
  • Review the current levels and consider stockpiling of the following antivirals, bronchodilators, mucolytics and antibiotics (Tamiflu,Relenza, Alupent, Atropine, Pulmicort, Ventolin, Atrovent, Xopenex, Pulmozyme, Intal, Racemic Epi, Mucomyst, Brethine, Lidocaine, Tobramycin and Duoneb)
  • Develop a system for tracking and reporting employee sickness/absenteeism and confirmed and suspect influenza illness.
  • Review /revise any applicable policies and procedures as necessary

Vaccine/Antivirals /
  • Implement campaign to promote and conduct mass vaccination for routine flu and pneumonia
  • The administration of the influenza vaccine shall be documented in the inpatient and outpatient medical record

Surveillance
Screening
Triage /
  • Actively participate with the local health department in ongoing syndromic surveillance.
  • Participate in the Electronic Syndromic Surveillance System (ESSS)
  • Report laboratory values via ECLRS.
  • Infection Control, Laboratory and Emergency Department personnel will collaborate to report HERDS data as directed by NYSDOH.
  • Infection Control will review the Real Time Outbreak and Disease Surveillance (RODS) weekly
  • Infection Control / Hospital Epidemiologist will monitor national, regional and local data related to pandemic influenza and regularly report trends to the Emergency Preparedness Committee and the Infection Control Committee, as well as other interested parties.
  • Infection Control and Employee Health will monitor communications from public health officials to review changes in recommendations from the CDC, the New York State Department of Health and the local county health department. Any changes in screening criteria will be communicated to the clinicians immediately.
  • All staff, volunteers and students will be screened by Employee Student/Health for development of new cough
  • Employee Health will screen staff and volunteers who report pneumonia or respiratory infection to identify possible clusters in health care providers. Clusters will be reported to Infection Control
  • Any staff member or volunteer with signs or symptoms of influenza must leave their work area and report to Employee Health for assessment. Students will be referred to Student Health Services.
  • All outpatients will be screened for the development of a new cough that has developed within the last 10 days, per guidelines in appendix G.
  • Place all patients with fever and new cough on droplet precautions pending further evaluation
  • Screen all patients at the time of admission for “fever, cough” per guidelines in Appendix F.
  • All staff will advise persons with fever and cough to defer visiting
  • Admit patients with fever and new cough to a private room with droplet precautions or cohort at the recommendations of Infection Control. Notify receiving unit of the need for precautions
  • Document data at time of screening and relay inpatient admitting diagnosis to Infection Control daily for review

Emergency Response /
  • Employee Health will provide multiple opportunities for staff, volunteers and students to receive influenza vaccine conveniently and efficiently
  • Nursing will carry out standing orders for all eligible patients to be offered and receive influenza vaccine in all outpatient care settings and prior to discharge from all inpatient units
  • Coordinated with local health departments and other emergency response partners on plans for alternate triage/care centers

Infection Control/Precautions /
  • Infection Control / Hospital Epidemiologist and Employee Health will monitor communications from public health officials to review changes in recommendations from the CDC, the New York State Department of Health and the local health department. Any changes in screening criteria will be communicated to the clinicians immediately. Infection Control will report to the Infection Control committee on a regular basis, as well as other interested parties.
  • All staff, volunteers and students will use Droplet precautions for all contact with any patient with new cough and fever until diagnosis of a non-contagious respiratory illness or an infection requiring a higher level of protection is made
  • Visible doorway precautions sign will advise the type of personal protective equipment required
  • Adequate supplies of surgical masks, waterless hand rubs and tissues will be maintained in public areas and waiting areas
  • Adequate supplies of personal protective equipment will be maintained including gloves, gowns, surgical masks, N-95 masks and PAPRs
  • Physical Plant will maintain negative pressure capable rooms

Access Control /
  • Public Safety will control access to the hospital

Communications /
  • Public Affairs/Media Relations will develop a sustainable and effective plan for communications and promotion of messages related to pandemic influenza to internal and external audiences
  • The Pandemic Influenza Planning Group will ensure the establishment of an internal communications plan to allow immediate access to predefined groups of staff via email, intranet, paging system and telephone.
  • The Pandemic Influenza Planning Group with the assistance of the Infection Control Committee will act as consultants to Human Resources’ Corporate Education and Training to develop a sustainable plan to orient and educate staff regarding the basic readiness activities and “just in time’ education to provide timely information to providers in the event of a pandemic influenza. This will include information on educational teleconferences, web-based programs and programs presented locally. Educational resources will be maintained on the hospital intranet.
  • Pandemic education for staff volunteers and students will be developed that includes an explanation of the changes in policy and procedure, if any, as the epidemic progresses
  • Pandemic Flu education through the CDC, in English, Spanish and French, will be accessible on the hospital intranet.
  • Employee Health will present regular update of physician compliance with influenza vaccine by department.
  • Employee Health will track and report influenza vaccine rates among direct care providers.
  • Human Resources’ Corporate Education and Training, in conjunction with EmployeeHealth, will develop educational and promotional material to promote availability and desirability of influenza vaccine for all.
  • Public Affairs/Media Relations will maintain signs at the entrances asking visitors to avoid visiting or wear a mask and use tissues if they have a new cough and use good hand hygiene while visiting the hospital.