Influenza (Flu) and Viral Respiratory Tract Infection - … · Web viewSeasonal influenza and other viral respiratory tract infections are very common and are usually acquired and

Influenza (Flu) and Viral Respiratory Tract Infection - Testing and Isolation Precautions for Adults UHL Guideline

Trust reference: B35/2017

1. Introduction

1.1. Seasonal influenza and other viral respiratory tract infections are very common and are usually acquired and managed in the community. This guideline focuses on those patients with more severe illness which requires hospital admission and the measures taken to limit spread within the hospital.

1.2. In the event of a seasonal Influenza outbreak, hospitals are likely to be working to maximum capacity, even in the absence of ‘winter pressures’. The increased demand upon services will be further compounded by staff sickness and the absence of staff caring for members of their family. Lack of staff is likely to impact the number of beds and level of service that the Trust can maintain. Therefore it is imperative that there should be contingency plans in place to deal with these eventualities.

1.3. The following guideline is to be used for all patients with respiratory illness of a known or suspected viral cause including Influenza. This document is not intended to provide clinical treatment advice but to highlight the precautions used when managing patients with viral respiratory tract infection

1.4. UHL Antiviral treatment/ prophylaxis information is available; For guidance on influenza antiviral treatment

2. Scope

2.1. The guidance is intended for use by Medical and Nursing staff involved with adults presenting with symptoms of seasonal influenza or respiratory viruses within UHL

For children’s; guidance- Respiratory Viral Illness (Including Flu) Infection Prevention UHL Childrens Guideline. Trust reference: D10/2019

2.2. This document is not intended to provide advice on episodes of pandemic flu. In the event of a pandemic (defined as a higher than normal level of influenza activity in the population of Leicester/shire), a UHL pandemic outbreak group will be convened, the aspiration of which would be:

Patients will be admitted through the ED at LRI and CDU at Glenfield Hospital. Wherever possible patients will be isolated in side rooms. Where a patient’s condition deteriorates and they require intensive support the

ITUs at the LRI and Glenfield will be used.

2.3. An influenza pandemic would impact on ITUs because of the need to provide respiratory support to many patients. This will affect the ability of the ITUs to support post-operative patients and emergency medical patients admitted for other reasons. Decisions on how to respond to this extra workload and its impact on other patients and patient flow would be directed by the pandemic outbreak group.

Influenza (Flu) and Viral Respiratory Tract Infection - Testing and Isolation Precautions for Adults Guideline Page 1 of 13Latest version approved by Policy and Guideline Committee on 20 December 2019 Trust Ref: B35/2017 Next Review: Dec 2022

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

http://insitetogether.xuhl-tr.nhs.uk/pag/pagdocuments/Respiratory%20Viral%20Illness%20(Including%20Flu)%20Infection%20Prevention%20UHL%20Childrens%20Guideline.pdf

http://insitetogether.xuhl-tr.nhs.uk/pag/pagdocuments/Respiratory%20Viral%20Illness%20(Including%20Flu)%20Infection%20Prevention%20UHL%20Childrens%20Guideline.pdf

http://insite.xuhl-tr.nhs.uk/antibiotic/



2.4. Consequently, UHL’s intention would be to try to maintain an emergency and elective service at the LGH, whilst there are the appropriate support facilities there. Should the position deteriorate further UHL could seek surgical support from the private sector hospitals (Spire and Nuffield).

3. Guidelines and Procedures 3.1. It is important to inform the Infection Prevention Team (IPT) using the electronic system

on ICE of any patients who are being investigated for influenza or respiratory viruses to ensure that patients are isolated appropriately.

3.2. The fundamental principles of managing patients during an outbreak of influenza are meticulous use of infection control requiring segregation, isolation and cohort nursing including stringent attention to hand and respiratory hygiene. The use of surgical masks and respirators has a role to protect staff, provided they are used correctly in conjunction with other infection control measures.





4. Early Detection of Influenza type symptoms Public Health England have developed a flowchart to identify symptoms of Influenza and appropriate management as below

Management of patients with flu like symptomsFor further advice please contact Infection Prevention on 5448 or Out of Hours via

Microbiology via Switchboard





Please use this Source Isolation poster for patients with suspected / confirmed Influenza

Please isolate in side room with door closed,Inform IP on ICE Complete Source Isolation Risk Assessment,

Where isolation into a side room is not possible complete a Datix reportUse IPP influenza -INsite - Infection Prevention Pathways

This information is to be used for seasonal influenza strains.More information on Influenza and respiratory infections is available on

INsite - Influenza/Respiratory Precautions This includes; Flu Algorithm- Ordering codes for masks and other PPE.

If there is any history of foreign travel associated with respiratory symptoms please inform IP, isolate and investigate other organisms in line with;Fever in the Returning Traveller – Adult Guideline Fever in the Returning Traveller – Adult UHL Guideline.pdf Trust reference: B4/2019

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/732267/Algorithm_case_v31-Aug2018.pdf





http://insitetogether.xuhl-tr.nhs.uk/pag/pagdocuments/Fever%20in%20the%20Returning%20Traveller%20%E2%80%93%20Adult%20UHL%20Guideline.pdf

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http://insite.xuhl-tr.nhs.uk/homepage/clinical/infection-prevention/organisms/influenzarespiratory-precautions



During Flu season there will be an escalating framework to manage patients with influenza;A guide to Manage Patients and Beds: Flu-like illness possible Influenzahttp://insitetogether.xuhl-tr.nhs.uk/SP2007/Infection%20Prevention%20and%20control/SOP%20For%20Influenza%20Beds.pdf

5. Testing for Influenza

5.1. Green top viral swabs.Viral samples can be taken from the nose or throat using a green topped viral swab



http://insitetogether.xuhl-tr.nhs.uk/SP2007/Infection%20Prevention%20and%20control/SOP%20For%20Influenza%20Beds.pdf

http://insitetogether.xuhl-tr.nhs.uk/SP2007/Infection%20Prevention%20and%20control/SOP%20For%20Influenza%20Beds.pdf



5.2. If a POCT is available some of the fluid from this swab tube can be used for the rapid POCT (see appendix 1) before sending it to the Virology lab.All samples are sent to the lab to test for Influenza and respiratory viruses (parainfluenza PIV, respiratory syncytial - RSV, adenoviruses - AdV, etc.).Request sample on ICEIf rapid tests are being used ; please sample for rapid test and then send swab to virology.

All other areas send swab to virology with request from ICE.

Access ICE Log in Requesting Input patients s number Click on correct patient New request Micro/ virology ( Top boxes) Left hand side- UHL PCR test Respiratory virus PCR

5.3. The lab test will take approximately 4 hours from the start of the test so should be sent promptly to the labs for testing to avoid prolonged delays. Transportation of samples will be arranged across the 3 sites, contact Porters for specific site details.

6. Management of patients with suspected or confirmed Influenza

6.1. All patients with suspected Influenza should be nursed in a side room. When there is no side room capacity, where possible, draw the side curtains around the bed space to reduce aerosolisation to patients either side. Maintain source isolation precautions in bed space, until a side room is available.

7. Patients with high suspicion of Influenza- awaiting results 7.1. Any patients with an influenza-like illness should be treated with antiviral medication

immediately, tested as quickly as possible while waiting for results the patient should be isolated in a side room.

7.2. Please note that empirical treatment with antivirals for influenza does not stop viral shedding immediately. The antiviral drugs only prevent further viral replication of influenza – any existing virus can still be shed for several days until the host immune response clears this. Thus, in immunocompromised patients, this period of viral shedding may be prolonged as a weakened immune response will more slowly clear any existing virus from the respiratory tract.

7.3. If a side room is not available the patient should be nursed in a bed space in a bay, with the side curtains drawn, creating a temporary makeshift isolation cubicle. Surveillance and increased monitoring of other patients should be undertaken and on discussion with Virology and the IP team antivirals may be considered for patients in the bay.





8. Cohorting patients with Laboratory confirmed Influenza 8.1. Patients with a laboratory confirmed diagnosis of the same strain of Influenza may be

cohorted together in a bay or designated area. Patients with influenza A should not be cohorted with patients infected with influenza B (i.e. a different influenza type)

8.2. The decision to cohort patients with the same respiratory strain of virus is made by the Infection Prevention team or Microbiologist. The Duty Manager must be informed. Please refer to Managing increased Incidence and Outbreaks of Infection in Hospitals Policy. - Infection in Hospital Increased Incidence UHL Policy.pdf

8.3. If patients with laboratory confirmed influenza have other infectious conditions such as Clostridium difficile or MRSA then they should not be cohorted with other patients but placed in a side room in source isolation.

8.4. Where a bay of patients are cohorted;Separate dedicated teams of nursing/domestic staff must be allocated to the cohort area and they must follow correct infection control procedures, including the use of PPE and hand hygiene. This must be maintained across all shift patterns during the outbreak. If separate staff cannot be allocated across all shift patterns then the whole ward will need restricting to admissions.

8.5. Separate domestic staff are required for cleaning in the cohort area, paying close attention to surfaces that staff and patients frequently touch such as door handles and cot sides. A second team will clean unaffected areas of the ward and provide food preparation to unaffected patients.

8.6. Any staff attending the ward to offer therapy services should limit their number to the minimum required to provide safe care.

8.7. Clear Infection Prevention stop signs should be clearly visible to alert staff and visitors to a restricted area.

8.8. Gloves and aprons must be changed and hands decontaminated before and after contact with different patients in the cohort bay. Surgical masks must be removed when leaving the cohort area but can be kept on between patients.

8.9. Patients may be encouraged to wear masks (Surgical masks)if they are highly symptomatic/ sneezing / coughing etc during cohorting, this reduces the risk of transferring their viruses to others, however this may be difficult for patients to tolerate and priority should be given for side rooms for highly infectious patients. For more advice consult the Consultant Virologist.

8.10.Patients with confirmed or suspected influenza must not visit communal parts of the hospital such as the canteen.

8.11.Visitors entering the area should clean their hands before leaving the area. The use of a mask is dependent upon the level of contact with the patient and should be advised by staff.



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8.12.Segregation of patients in some specialist areas may be difficult. Examples of this may include areas such as critical care. In this instance side rooms in the area may be required for the protective isolation of patients without flu symptoms and patients with flu may need to be cohorted in the bays.

9. Aerosol generating procedures 9.1. Aerosol generating procedures produce droplets less than 5 microns in size which may

cause infection if they are inhaled. These small droplets containing pathogens can remain in the air, travel over distances and still be infectious.

9.2. Aerosol generating procedures should ideally take place within a side room, or enclosed area and must only be carried out if absolutely necessary. Examples of aerosol generating procedures include intubation, CPR, bronchoscopy and non-invasive ventilation. If a side room is not available the curtains must be closed around the bed space during the aerosol generating procedure.

Aerosol ge n erating procedures incl u de:

• Intubation, extubating and related procedures e.g. manual ventilation and open suctioning

• Chest physiotherapy• Cardiopulmonary resuscitation• Bronchoscopy• Surgery and post mortem procedures in which high-speed devices are

used• Dental procedures• Non-invasive ventilation• High frequency oscillatory ventilation

9.3. Although PHE guidance has suggested that aerosol generating procedures currently do not include nebulisation of medication or administration of pressurised humidified oxygen, evidence is accumulating that there is a potential risk from this. Please draw the side curtains around such patients during the use of these devices wherever possible. The curtains can be opened once the use of these masks has finished.

9.4. Aerosol generating procedures must only be carried out when essential and should be done ideally in a well-ventilated single room with the doors shut.

9.5. The rate of clearance of aerosols in an enclosed space is dependent on the extent of any ventilation. The greater the number of air changes per hour the sooner aerosol will be cleared.

9.6. Fans should not be used in affected areas, windows can be opened, and curtains drawn at the side of beds in cohort areas where possible to reduce the risk of aerosol transmission.

10. Criteria for ceasing source isolation 10.1.Adults should have had 5 consecutive days of antiviral treatment and are asymptomatic Influenza (Flu) and Viral Respiratory Tract Infection - Testing and Isolation Precautions for Adults Guideline Page 8 of 13Latest version approved by Policy and Guideline Committee on 20 December 2019 Trust Ref: B35/2017 Next Review: Dec 2022




for 24 hours. Then source isolation precautions can cease.

10.2.For those patients who remain symptomatic, discuss with IPT before ceasing source isolation.

10.3.When isolation is ceased the affected area requires an AMBER clean, which includes a thorough environmental clean of the affected area, equipment and a curtain change by the domestic team.

10.4.Please note that empirical treatment with antivirals for influenza does not stop viral shedding immediately. The antiviral drugs only prevent further viral replication of influenza – any existing virus can still be shed for several days until the host immune response clears this. Thus, in immunocompromised patients, this period of viral shedding may be prolonged as a weakened immune response will more slowly clear any existing virus from the respiratory tract.

11. Surge Capacity Options 11.1.The UHL surge capacity response to managing patients with Flu is outlined below. Any

decisions to cohort patients once side room (including IDU) capacity has been exhausted must be sanctioned by the Outbreak Control Group based on the options below;

Patient Flu Status Cohort Arrangements

Influenza like illness – not confirmed

Immediate treatment with antivirals until conclusive test results are available

Allocate to side room

General Medical Patients Laboratory confirmed Influenza (LRI)


IDU (up to 4 patients)

Cohort on ward 23 LRI

Treatment with Antiviral

Cardiology and Respiratory Patients with Confirmed Influenza (GGH)


F20 Extra capacity ward

F33a, F32 ,USE of Derby doors

Cohort ward F15.

Treatment with Antivirals





Cancer Haematology Patients Laboratory confirmed Influenza

Allocate to side roomIDU (up to 4 patients)Cohort on 42 or 43Treatment with Antiviral

Maternity Patients Laboratory confirmed Influenza


IDU (up to 4 patients)

Influenza Negative Treated within normal arrangements

12. Cancer and Haematology 12.1.All patients on admission in Cancer and Hematology will be assessed for symptoms of

influenza and respiratory illness between October and March. If they have flu like symptoms they will be isolated, screened and treated. The screening process will involve; near patient test and samples sent to the labs.

12.2.Isolation will take place in side rooms for all symptomatic and confirmed flu patients, any side room in ward 39 or 40 can be used however only the negative pressure side rooms on ward 41 can be used. If demand outstrips side room availability on 39, 40 and 41 an additional 4 patients can be isolated on the Infectious Diseases Unit. If demand continues to exceed the available side rooms on 39, 40, 41 and IDU then cohorting arrangements should be implemented on wards 42 or 43. To manage the spread of infections, all bay doors and corridor doors will be kept closed and the air conditioning flow rate within the bays will be adjusted to create a relative negative pressure area within the bays and positive pressure within the corridors.

12.3.Once the cohorting threshold has been reached an outbreak incident management meeting must be convened. Patients that are being cohorted should where possible remain in their bed space (within the curtain track). If a patient leaves the bed space they must wear a surgical mask.

12.4.All staff coming into contact with symptomatic flu patients should wear a surgical mask whilst they are in the cohort bay.

12.5.All staff are offered the seasonal influenza vaccine free of charge, through occupational health at UHL. It is especially important for those working in higher risk areas, such as cancer and haematology, where the risk of transmission from staff to patients is potentially much more harmful.

12.6.Line managers should help to promote uptake by the use of positive messages about the benefits of vaccination to staff members, their families and their patients.

13. Respiratory and Cardiology Patients (CDU)13.1.Early Identification of patients with Flu like symptoms is essential. Any patient with flu

like symptoms and a high suspicion of influenza, will be isolated, screened for influenza Influenza (Flu) and Viral Respiratory Tract Infection - Testing and Isolation Precautions for Adults Guideline Page 10 of 13Latest version approved by Policy and Guideline Committee on 20 December 2019 Trust Ref: B35/2017 Next Review: Dec 2022




and treated. The screening process will involve; near patient test and samples sent to the labs – please see section 8.6.

13.2.Isolation will take place in any side room on any respiratory ward for all patients with a high suspicion of influenza and immediately start treatment with antivirals. If side room availability is limited within respiratory, then side rooms on other base wards should be used. Should demand outstrip available side rooms across the Glenfield site then an outbreak meeting should be convened to discuss cohort nursing on a respiratory ward. Staffing of cohorted areas will required dedicated staffing for all shifts for the duration of the outbreak.

13.3.Patients can be cohorted and dedicated isolation areas can be set up with the use of the inflatable Derby Doors. The outbreak group will liaise with Estates and Facilities to request that the Derby Doors are set up in the chosen locations. For the list of details of where these can be set up, please consult Estates and Facilities.

14. Critical Care – Adults. 14.1.There may be a requirement to increase the Trust’s ability to provide additional Level 3

Critical Care capacity. Planning assumptions dictate that this could potentially be a 100% (double capacity) increase. This will have a negative impact on elective theatre capacity across all CMGs with elective surgical services.

14.2.When demand for critical care services threatens to exceed capacity, pressure on healthcare services can be mitigated initially by careful selection of patients for hospital assessment and admission, and subsequently by a coordinated approach to patient pathways to higher levels of care. Provision should also be made for interim, respite or step down for patients who are less likely to benefit from critical care, or who have received critical care but now require a lower level of care.

14.3.In order to manage the demand on adult critical care and ECMO, admission criteria to each unit may be adjusted to overspill adults into paediatric ICU or vice versa, size rather than age may be used to identify suitable patients for movement. It will be for the clinical team to discuss each case on a case by case basis and will require the approval of the teams involved to ensure patient safety. This will apply when either unit is unable to safely manage its patients with the resources available. Staffing levels will need to flex and be reallocated between adults and paediatrics to meet current national guidelines on minimum levels of staff based on the clinical dependency of the patients.

14.4.In order to effectively manage patients in critical care during outbreaks of Influenza all ECMO activity will be undertaken at the Glenfield site. During periods of increased activity of Influenza a review of level 2 and 3 critical care patients will be completed across all 3 ITU sites in UHL. Capacity of all critical care beds will be closely monitored and coordinated by Children’s and ITAPS CMG management teams.

14.5.Where additional capacity is created this must be coordinated with other supporting services to ensure that they are able to meet the new service requirements.

15. Management of patients with RSV





15.1.The hospital has a limited amount of side rooms which are at a premium in the winter period, due to the lack of side room capacity and isolation facilities;

15.2.A patient with Flu A or B should be isolated in a side room, as a priority

15.3.Ideally patients with RSV should be isolated in the same way , but when side rooms are not available, isolate in the bay with side curtains pulled to protect patients either side from aerosolisation from sneezing etc.

15.4.Undertake a risk assessment of patient groups as RSV can cause complications in adults with pre-existing lung conditions like asthma, COPD, bronchiectasis, etc. immunocompromised and transplant recipients are at risk of severe disease with RSV and parainfluenza virus.

16. Post infection cleaning 16.1.Information on post infection cleaning can be found in; Healthcare environment

cleaning policy and procedures Cleaning - Healthcare Environment UHL Policy.pdf

17. Education and Training

17.1.New POCT documentation and training sessions developed and completed by UHL POCT team.

18. Supporting References Public Health England, 2019 Point of care tests for influenza and other respiratory viruses

UHL - Managing increased Incidence and Outbreaks of Infection in Hospitals Policy B11/2006

19. Key Words Influenza, flu, RSV, respiratory viruses, , flu flow chart, POCT,

CONTACT AND REVIEW DETAILSGuideline Lead (Name and Title)Janice Blount

Executive Lead: Carolyn Fox Chief Nurse

Details of Changes made during review:Title change to include- (Testing and isolation precautions)Signpost to treatment guidelines 1.4All links checked.





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Appendix 1

Point of Care Testing Machines (POCT) For early detection of Influenza and Respiratory Synovial Virus (RSV) for adults and children

The Cepheid GeneXpert system is available for use by trained and competent staff in the following locations: Clinical Decisions Unit at the Leicester Glenfield Hospital. Emergency Department (Paeds) and Hambleton Suite at the Leicester Royal Hospital.

The Xpert Xpress Flu/RSV assay provides rapid results to identify patients suffering from seasonal viruses such as Flu and RSV. This allows effective control, improved choice of treatment and potential prevention of outbreaks,

The aim of testing for influenza and RSV with these particular assays at University Hospitals of Leicester is to improve on turnaround times to help manage patients coming into the Emergency Department (LRI), Clinical Decisions Unit (GH) and in Oncology/Haematology (LRI) with influenza like symptoms. The aim is to help improve turnaround of decisions on discharge or isolation, efficiency of antiviral administration, and appropriate cleaning of patient rooms once vacated. With the overall aim of reducing influenza outbreak and hospital acquired viral disease.

The rapid test uses the same viral transport sample media for nasal or throat or naso-/oro-pharyngeal swabs as the normal lab test. The swab in the tube must be labelled with the patient demographics prior to POCT testing.

Please also indicate site of sample – NOSE/ THROAT or NPA.The cartridge supplied with the kit requires a small sample (300µL) to be added into the appropriate well and then is processed as a closed system. The test will identify influenza A, B and RSV with the test result available within 20 minutes. This test will not subtype the influenza infection.

All results from the POCT must be recorded in the patient’s notes, or locally agreed procedure, for analysis and comparison with the in-house laboratory results periodically, to check that the performance is satisfactory.

The swab in the tube should be labelled and sent to the lab as usual to confirm the POCT results but also to test for other respiratory viruses (parainfluenza - PIV, respiratory syncytial - RSV, adenoviruses - AdV, etc.) not covered by the POCT. The lab test will take approximately 4 hours depending on the hospital site from the start of the test so should be quickly sent to the labs for testing to avoid prolonged delays.

