Case Study Module 4 Part 2

1. Case StudyModule 4 Part 2 Patient Management

2. Case Management of Suspect Human Avian Influenza Infection Part 3: Triage of Suspected Avian Influenza Cases

3. 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

4. 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

5. 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

6. Steps for Triage of All AI Cases 1. 2. 3. 4.

7. Triage Step 1 Determine Type and Severity of Illness

8. 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

9. 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.htm

10. CURB-65 Interpretation 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 * low numbers and very broad confidence interval

11. CRB-65 Interpretation • CURB-65 scoring, without lab test for Urea (blood urea nitrogen) • Has not been confirmed in large studies * low numbers and very broad confidence interval

12. 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

13. Pneumonia SeverityRating 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?

14. Case Report

15. 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

16. CRB-65 CategoryPoints Given Confusion 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 Rate Pneumonia Severity Total Points for modified CRB-65 2 Moderate risk of death; consider hospital admission

17. Triage Step 2 Assess Level of Care Needed

18. 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

19. 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

20. Triage Step 3 Assess Available Healthcare Resources

21. 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 Healthcare Facilities

22. Healthcare Facilities Know your area facilities: • Location • Capability • Capacity

23. Healthcare Facilities Question 1 What healthcare facilities are available in your area? Question 2 What level of care can be provided at these facilities?

24. Triage Step 4 Advise on Referral and Transport of Patients

25. 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 Referring Patients to Another Facility

26. 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

27. 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?

28. Problem Solving Exercise

29. Public Health Steps for Managing Cases

30. Additional Steps Necessary • Assess presence of illness among contacts • Advise on management of corpses with possible avian influenza • Determine need for isolation and quarantine • Document data on standardized forms and report to relevant authorities

31. 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

32. 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

33. 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 Advise on Isolation and Quarantine

34. 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 Advise on Isolation and Quarantine

35. 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

36. Document and Report Cases World Health Organization Ministry of Health District or Provincial Level Local Level

37. 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

38. Document and Report Cases Information to include • Name of person reporting • Healthcare facility name and location • Patient information: Demographics Travel history Symptoms Avian flu in area animals Test Results Potential exposures Treatment given Outcomes

39. Document and Report Cases http://www.who.int/csr/disease/avian_influenza/guidelines/globalsurveillance.pdf

40. 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

41. 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

42. Case Study Scripted Role Playing Activity

43. Glossary Triage A system of carefully using medical resources where they are needed most.

44. 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