Transcript Case Management of Suspect Human Avian Influenza Infection

Case Study
Module 4 Part 2
Patient Management
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Case Management of Suspect
Human Avian Influenza Infection
Part 3: Triage of Suspected
Avian Influenza Cases
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Learning Objectives
• Define triage
• Know the function of each of the four
steps in a triage approach
• Recognize the utility of triage in avian
influenza case management
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Session Outline
• Triage and pneumonia severity ratings
• Assess the level of care needed
• Assess available healthcare facilities
• Advise on referral and transport of patients
• Assess illness in contacts, determine whether to
recommend treatment or isolation of cases, contacts
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Triage Defined
• Triage is a system of carefully using
medical resources where they are
needed most
– Decisions about who is the most ill
– Decisions about who will respond best to
care
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Steps for Triage of All AI Cases
Steps
Example
Determine type and
severity of illness
1.
Patient has pneumonia
Assess level of care
needed
2.
Does the patient need
Antivirals? Oxygen? A
ventilator?
Assess available health
3.
care resources
Does the health care
facility have a ventilator?
Advise on patient referral Does a nearby facility
and transport
have a ventilator? Can
4.
the patient make the trip? 6
Triage Step 1
Determine Type and Severity of Illness
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Determining Severity of Illness
• For avian influenza, prioritize by severity
of pneumonia
• Systems for rating pneumonia severity
– Pneumonia Severity Index
– CURB-65
– Pneumonia Severity Scoring System
• Scores assigned to show urgency of
hospital admission
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CURB-65
•
•
Developed the British Thoracic Society
One point each for:
–
Confusion (new disorientation in person, time or place)
–
Urea, or blood urea nitrogen (BUN) level above 7 mmol/L
(urea) or 20 mg% (BUN)
–
Respiratory rate >= 30 breaths/min
–
Blood pressure < 90 mm Hg systolic OR =<60 mm Hg
diastolic
–
Age >= 65 years
Source:
http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/btsscore.ht9
m
CURB-65 Interpretation
Score
Predicted
Mortality (%)
0
1
2
3
4
5
0.9
1.1
5.2
12.0
32.4
25*
* low numbers and very broad confidence interval
Score 0:
Low risk of death; may be suitable for home treatment
Score 1:
Increased risk of death; consider hospital referral and
assessment or home treatment
Score 2:
Increased risk of death; consider for short inpatient treatment
or supervised outpatient
Score >=3:
High risk of death; Require urgent hospital admission
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CRB-65 Interpretation
Score
Predicted
Mortality (%)
0
1
2
3
4
0.9
5.2
12.0
32.4
25*
* low numbers and very broad confidence interval
• CURB-65 scoring, without lab test for Urea
(blood urea nitrogen)
• Has not been confirmed in large studies
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Pneumonia Severity Ratings
• Do not rely solely on scores
– Scores serve as a guideline
– Consider the patient’s clinical information
– Use best judgment based on expertise
• Adapt rating systems to local capacity
– Pulse-oximetry to measure oxygen in
blood
– Availability of blood pressure monitors
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Pneumonia Severity
Rating Systems
Question 1
What elements of the rating systems do
you think are most useful?
Question 2
How might the system be adapted for
your area?
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Case Report
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A Patient in China
• Female, unknown age, 4 months pregnant
• Presents at hospital November 7
• Symptoms
–
–
–
–
–
–
–
Trouble breathing
Cyanosis (blue-colored skin)
Fever 38.8°C
Pulse 118 beats / minute
Respiratory rate 37 breaths / minute
Lymphocyte count 608 / mm3
Chest x-ray shows diffuse infiltrates in the lower
part of both lungs
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Rate Pneumonia Severity
CRB-65 Category
Confusion
Points Given
0
Respiratory rate >= 30 breaths/min
1
Blood pressure < 90 mm Hg systolic OR
=<60 mm Hg diastolic
[Pulse > 125 beats / min]
1
Age >= 65 years
0
Total Points for modified CRB-65
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Moderate risk of death; consider hospital admission 16
Triage Step 2
Assess Level of Care Needed
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Hospitalization Not Needed
• Patient may be cared for at home
• Administer appropriate antiviral if
avian influenza suspected
• Teach patient and family
–
–
–
–
Wash hands
Ill person uses a surgical mask
Limit social contacts
Symptoms in patient or family
members that require prompt
medical care
• If possible, follow-up with home
visits or by telephone
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Hospitalization Required
• Illness is not an emergency
– Monitor for changes in status
– Treat with antiviral
– Treat as necessary with
• Antibiotics
• Oxygen
• Severe illness
– Patient admitted to intensive care unit
– Ventilation or advanced medical support for organ
failure may be necessary
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Triage Step 3
Assess Available Healthcare Resources
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Healthcare Facilities
Clinic
• Local level
• Community
healthcare
• Outpatient services
Hospital
• Local or district
level
• More laboratory
capacity
• Inpatient services
Referral Hospital
• Larger cities
• Advanced medical care
• Laboratory diagnosis
• Isolation rooms
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Healthcare Facilities
Know your area facilities:
– Location
– Capability
– Capacity
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Healthcare Facilities
Question 1
What healthcare facilities are available in your
area?
Question 2
What level of care can be provided at these
facilities?
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Triage Step 4
Advise on Referral and
Transport of Patients
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Referring Patients to
Another Facility
Logistical considerations
•
•
•
•
•
Treat all patients at one versus a few sites?
When to transport patients to higher level facilities
How to transport patients to higher level facilities
Staff availability
Availability of overflow areas
Treatment considerations
•
•
•
•
Access to antivirals and antibiotics
Access to a laboratory for diagnosis
Access to radiology (x-ray)
Availability of isolation rooms
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Patient Transport Example
Female patient, Thuy, with pneumonia
admitted to primary level hospital
• The only patient suspected of avian influenza
• Symptoms: fever, high pulse and respiratory rate,
crackles heard in lungs
• Primary hospital can administer oxygen and
antibiotics, but has no access to x-ray or antivirals
• Tertiary hospital can x-ray patient and place on
ventilator support, if needed, but has no antivirals
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Patient Transport Example
Question 1
Would you recommend transporting Thuy to
the tertiary care hospital?
Question 2
What if Thuy was one of many severe
pneumonia patients at the primary hospital?
Question 3
What do you think are the most important
criteria for deciding to transport a patient?
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Problem Solving Exercise
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Public Health Steps for
Managing Cases
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Additional Steps Necessary
1. Assess presence of illness among contacts
2. Advise on management of corpses with
possible avian influenza
3. Determine need for isolation and quarantine
4. Document data on standardized forms and
report to relevant authorities
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Assess Contacts
• Assess contacts quickly
– Incubation period only 2 to 3 days
• Contact - anyone who has touched or talked
with (=<1 meter) the patient up to 2 or 3 days
prior to the patient’s onset of illness
– Household members
– Fellow workers
• Assess contacts for influenza-like illness
–
–
–
–
Fever
Cough, shortness of breath
Muscle aches
Diarrhea
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Manage Corpses
• No risk of transmission from dead bodies
• Autopsy procedures could result in transmission
– Use appropriate protective equipment
• You should know
– Where corpses may be sent for disposal
– Cultural or religious beliefs to respect when handling
corpses
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Advise on Isolation and Quarantine
Isolation
• Separate or limit
movement of people
who are ill to prevent
them from infecting
healthy people
• Often occurs in a
healthcare setting
• For use when illness is
fairly rare
Quarantine
• Separate people who
have been exposed to
an illness (may not be
ill themselves)
• For use when illness is
widespread
• May cancel public
gatherings, large events
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Advise on Isolation and Quarantine
Length of time for isolation
and quarantine depends
on incubation period and
infectious period
Goals:
– Prevent additional human
cases early
– Slow pandemic spread (gain
time for preparing)
– Reduce the impact of the first
wave of a pandemic
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Document and Report Cases
• Help identify and describe old and new
strains of avian influenza
• Know where avian influenza is being
transmitted
• Track and count illness due to avian
influenza
• Provide information for influenza control
• Help officials make public health decisions
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Document and Report Cases
World
Health
Organization
Ministry of
Health
District or
Provincial Level
Local Level
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Document and Report Cases
“WHO Guidelines for Global
Surveillance of Influenza A/H5”
http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf
Annex 5
“Template for Case Report Form”
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Document and Report Cases
Information to include
• Name of person reporting
• Healthcare facility name and location
• Patient information:
Demographics
Symptoms
Test Results
Treatment given
Travel history
Avian flu in area animals
Potential exposures
Outcomes
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Document and Report Cases
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http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf
Document and Report Cases
When should you report?
• As soon as possible!
• Do not wait for laboratory confirmation
• Do not wait to observe patient outcome
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Summary
• Patients needing advanced care may need to be
transported to a higher level facility, while patients
with mild illness may be able to stay at home
• Medical treatment and care of patients will depend
on the facilities available in your geographic area
• People who have contact with a suspected avian
influenza case should be assessed for illness, and
may be given preventive treatment or put in isolation
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Case Study
Scripted Role Playing Activity
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Glossary
Triage
A system of carefully using medical
resources where they are needed most.
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References and Resources
• WHO interim guidelines on clinical management of
humans infected by influenza A(H5N1), 2 March
2004.
http://www.who.int/csr/disease/avian_influenza/guide
lines/clinicalmanage/en/index.html
• Tran Tinh Hien, et al. Avian Influenza A (H5N1) in 10
Patients in Vietnam. N Engl J Med March 18, 2004:
350(12), p 1179-1181.
• WHO pandemic influenza draft protocol for rapid
response and containment
Updated draft 30 May 2006.
http://www.who.int/csr/disease/avian_influenza/guide
lines/protocolfinal30_05_06a.pdf
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