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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

Patient has pneumonia

Assess level of care needed

Does the patient need Antivirals? Oxygen? A ventilator?

Assess available health care resources

Does the health care facility have a ventilator?

Advise on patient referral and transport

Does a nearby facility have a ventilator? Can the patient make the trip?

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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– CRB-65– Pneumonia Severity Scoring System

• Scores assigned to show urgency of hospital admission

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CRB-65

• Developed the British Thoracic Society

• One point each for:– Confusion (new disorientation in person, time or

place)

– Respiratory rate >= 30 breaths/min

– Blood pressure < 90 mm Hg systolic OR =<60 mm Hg diastolic

– Age >= 65 years

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CRB-65 Interpretation

Score 0: Low risk of death; may be suitable for home treatment

Score 1: Increased risk of death; consider for short inpatient treatment or supervised out patient

Score >=2: High risk of death; Require urgent hospital admission

Score 0 1 2 3 4

Predicted Mortality (%)

0.9 5.2 12.0 32.4 25*

* low numbers and very broad confidence interval

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Severity Assessment( Children) BTS

Mild Severe

Infants Temp.<38.5 C Temp.>38.5 CRR<50/min RR>70/minMild recession Moderate- severe recessionTaking full feeds Not feeding

Nasal flaringCyanosisIntermittent apneaGrunting respiration

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Severity Assessment( Children) BTS

Mild Severe

Older children Temp.<38.5 C Temp.>38.5 C

RR<50/min RR>50/min

Mild breathlessness Severe Breathlessness

No Vomiting Nasal flaring

Cyanosis

Grunting respiration

signs of dehydration

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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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Case Report

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Case Scenario

• Female, 32 years old

• 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 Points Given

Confusion0

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 0Total Points for modified CRB-65 2

Moderate risk of death; consider hospital admission

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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 FacilitiesStation Hospital• Outpatient services • limited laboratory capacity• Limited Inpatient services

Township/District Hospital• Outpatient services • More laboratory capacity• Inpatient services

State/Division Hospital• Outpatient services • More laboratory capacity• Inpatient services• Isolation rooms• ICU Service?

Referral Hospital

• Yangon& Mandalay

• Advanced medical care

• Advanced Laboratory diagnosis

• Isolation rooms

• ICU services

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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, 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 1Would you recommend transporting the patient to the

tertiary care hospital?

Question 2What if the patient was one of many severe pneumonia

patients at the primary hospital?

Question 3What 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

Local Level

District orState/Division Level

Ministry of Health

WorldHealth Organization

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Document and Report Cases

“WHO Guidelines for Global Surveillance of Influenza A/H5”

Annex 5

“Template for Case Report Form”

http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf

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Document and Report Cases

Information to include

• Name of person reporting

• Healthcare facility name and location

• Patient information:

Demographics Travel historySymptoms Avian flu in area animalsTest Results Potential exposuresTreatment given Outcomes

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Document and Report Cases

http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf

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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

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Scripted Role Play

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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/guidelines/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 containmentUpdated draft 30 May 2006. http://www.who.int/csr/disease/avian_influenza/guidelines/protocolfinal30_05_06a.pdf