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“Pandemic Planning” Oxfordshire Practice Manager Conference 21.1.09. (Paul Roblin 10:15am to 10:45am) Launched 07 January 2009 57 pages “Practice managers in particular should find it helpful” RCGP http://www.rcgp.org.uk/pdf/GP_Guidance.pdf BMA http://www.bma.org.uk/health_promotion_ethics/i nfluenza/panfluguiddec08.jsp?page=1 More to come Document will be updated regularly as ideas emerge. It is therefore important to visit the DOH website regularly: www.dh.gov.uk/en/Publichealth/Flu/Pande micFlu/index.htm. Buckman letter Practices should identify Buddying Groups (clusters of practices which actively cooperate for pandemic work) Pandemic Flu Contingency plan to be agreed between buddying group and PCT by March 31 2009. Anna Hinton (PCT operational lead) “Please send all updated plans to into PCT by 1/3/09” Tel: 01865 336858 Fax: 01865 337094 Mobile: 07900 212 454 email:firstname.lastname@example.org The Government‟s messages to the public will be: Stay at home Don‟t spread it around Phone the National Pandemic Flu Line Service not GP practices. Arrange a „flu friend‟ National Pandemic Flu Line 24-hour telephone line for the general public. Capable of activation from spring 2009. For the public to access antiviral medication Issue URN to collect antivirals from a local „collection point‟. GPs will receive referrals from the National Pandemic Flu Line Service call centre. Flu Line Professional Service (No public access) Doctor access to a patient‟s National Pandemic Flu Line record Bypasses National Pandemic Flu Line Service Check previous antiviral authorisations. Authorise an antiviral Generate a URN Uncertainties of Pandemic Planning Prediction is inaccurate Clinical attack rate could be 25% to 50%, (normal seasonal flu rate of 5% to 15%). Adaptability will be needed. Responses stepped up as appropriate. (Escalation) Overall case Range of possible excess deaths in the UK fatality rate (%) 25% clinical 35% clinical 50% clinical attack rate attack rate attack rate 0.4 55,500 77,700 111,000 1.0 15,000 210,000 300,000 1.5 225,000 315,000 450,000 2.5 375,000 525,000 750,000 Buddying-up system A buddying-up system is proposed Clusters of practices will actively cooperate for pandemic work, sharing resources and exchanging staff as necessary. Templates at www.rcgp.org.uk Tees Primary Care Services – Primary Care Continuity Agreement: Caduceus Medical Practice Influenza Plan: Role of LMCs Organising buddying groups. Ensuring no practice is left isolated Involved in making decisions about stopping non-essential work. 1918/19 „Spanish flu‟ 20-40 million deaths worldwide. 1957 Asian flu‟ 1-4 million deaths 1968 „Hong Kong 1-4 million deaths flu‟ Pandemic Spread It seems likely that a flu pandemic will start outside the UK, but within two to four weeks of the start of the outbreak in the host country it will affect the UK. It could spread around the UK in one to two weeks, with the peak incidence occurring only 50 days from the initial entry to the UK. There may be single or multiple waves It is likely that between a quarter and a half of the population will be affected. Practice Funding Financial protection of practices when they have to suspend some normal operations such as Quality and Outcomes Framework (QOF) work and enhanced services. More details can be found in Appendix 1 GP workload GPs will be looking after patients in the community who are more seriously ill than under normal circumstances About one-third of symptomatic patients will require assessment and treatment by a GP Other practice patients who get flu will be asked to self-care. Peak Weeks The duration of a pandemic is unknown The peak is likely to occur within 50 days of the first cases of pandemic flu appearing in the UK. 22% of cases likely to occur in the peak week. For a typical practice of three GPs with a list of 6,000 patients, that works out at 186 extra cases in the peak week of the pandemic. Bird Flu (A/H5N1 flu virus ) The worry is flu with the virulence of bird flu and the transmissibility of human flu A new strain of avian flu virus mixed with human flu virus is likely to transmit more easily to people Ethics At the peak of the pandemic it may be necessary to prioritise who will benefit most from treatment. No one will like this but it will be done in an ethical and objective manner. Scoring systems for hospital admissions are being validated at present Modelling suggests that up to 2.5% of all flu victims may die. Coronors Likely relaxation of the legal requirement to have seen the dead patient in previous 14 days . Possibly the period will increase from 14 days to 28 days. Flexible Certification Death Certificates: Doctors who have not attended the patient allowed. The same doctor could also complete a streamlined Cremation Form B. Need for a second cremation doctor will be suspended WHO Phases and UK Alert Levels 1. No new influenza virus subtypes detected in humans 2. Animal influenza virus subtype proposes substantial risk humans Pandemic alert period 3. Human infection(s) with a new subtype, but no (or rare) person-to-person spread to a close contact 4. Small cluster(s) with limited person-to-person transmission but spread is highly localised, suggesting that the virus is not well adapted to humans 5. Large cluster(s) but person-to-person spread still localised, suggesting the virus is becoming increasingly better adapted to humans Pandemic period 6. Increased and sustained transmission in general population UK alert levels come into play UK alert levels (x4): 1. Virus/cases only outside the UK 2. Virus isolated in the UK 3. Outbreak(s) in the UK 4. Widespread activity across the UK UK Alert Levels If a pandemic is declared, action will depend on whether cases have been identified in the UK and on the extent of spread. Therefore, for UK purposes, four additional alert levels have been included within WHO Phase 6. These UK alert levels are: 1. Virus/cases only outside the UK 2. Virus isolated in the UK 3. Outbreak(s) in the UK 4. Widespread activity across the UK Clinical Aims and Philosophy Minimise the spread of the flu virus: isolate flu patients wherever possible. Limit the morbidity and mortality from influenza Stay at home and self-care. Only certain patients will be seen by a GP or other healthcare professional. Only the most seriously ill should be sent to hospital (assessed as likely to benefit from specialist treatment) . Infectivity The incubation period: 1-4 days Most infectious soon after symptoms develop. Droplet spread and Hand-to-face contact Virus Survival on Surfaces Hard non-porous surfaces Flu viruses can survive >24h on Soft materials (nightclothes, magazines and tissues) Up to 2h (15 mins mainly) Surfaces and Hands Remove soft furnishings and toys during a pandemic. Flu viruses are easily deactivated by washing with soap and water or alcohol handrub cleaning surfaces with normal household detergents and cleaners. Good hand hygiene is essential Home visitors should carry personal packs of alcohol hand rub. Personal protective equipment (PPE) Fluid-repellent face masks should be worn by any healthcare worker who will have close contact (within one metre) of people with flu. Government to stockpile face masks These will be held centrally until a change in WHO flu phase status triggers dispatch to PCTs. The point at which the face mask supplies are distributed to GP practices will be for PCTs to determine. The masks will be supplied to practices free of charge. Storage in practices? Using Surgical Masks Surgical masks should: be worn once only and then discarded to an appropriate bin as clinical waste; hands should then be washed/cleansed after disposing of the mask. cover nose and mouth not be allowed to dangle round the neck after or between each use not be touched until disposed be changed when moist Groups If there is a surgery for flu patients, or a GP/nurse is visiting patients in a nursing home, it may be more pragmatic to wear a single mask for the whole time or until it becomes moist and needs replacing. Staff absence levels Primary care staff will get flu, or stay at home caring for children or other dependants. Up to half the workforce may require time off at some stage over the pandemic period (up to two weeks). At the peak of the pandemic up to a fifth of the workforce may be absent. Single-handed practices will be hit even harder and may become non-viable without support from „buddy practices‟. Staff Illness and Safety Any GP or member of staff who shows flu symptoms must be sent home immediately. Practice staff who have recovered from pandemic flu and feel well enough to work should have immunity and should be able to treat flu patients. Staff Contracts and Pay Alter staff contracts now Flexibility clause. to cover possible redeployment and/or altered hours of work. Additional overtime taken by staff during the pandemic must also be funded by the primary care PCT. Practice Continuity Plans All practices must have a service continuity plan. For advice on how to do this and what to include read the joint guidance produced by the RCGP and the GPC at: www.bma.org.uk/ap.nsf/Content/flupanprep?Op enDocument&Highlight=2,business,continuity www.rcgp.org.uk/default.aspx?page=3908. Photo ID Each practice should develop an electronic library of staff photographs Photo ID during a pandemic Fuel supply for their vehicles. Emergency Box Advised Suggested Contents Torch spare batteries standard phone for use with emergency line e-charging adaptor for mobile phone space blanket up-to-date copy of this document copies of the service continuity plan and the practice‟s pandemic flu plan prepared signs for surgery photocopied patient encounter forms (in case computers are down) a ream of A4 paper and writing materials for logging decisions and recording clinical treatments. Retired Doctors Retired doctors will be allowed to certify death The BMA is working with the DOH to help identify retired doctors willing to help in a flu pandemic. Legislation is proposed which would permit the GMC, under new emergency powers, to grant a doctor registration subject to conditions. PCTs would pay the costs of GMC registration for this purpose. Locum GPs Locums/freelance GPs must be included in preparation and training programmes, information cascades Photo databases PCTs will employ all available freelance locum GPs Arrangements being discussed at national level. Performers List checking now GP Registrars Training and teaching will stop Length of training period may well be affected. Training rotational post changes will be suspended during a pandemic (inside and outside hospital.) Litigation Risk Special edition of Good Medical Practice will cover what will be expected of doctors in a flu pandemic Doctors acting in good faith unlikely to be disciplined (The GMC and Defence Societies) Practice Actions now Staff contracts making voluntary changes. Staff telephone number database (including mobile numbers) Emergency Boxes Buddy Up Protocols “parachuted in” staff (Practice systems and IT use) Plan patient separation Daily “Sit” Reports Regular reports to a PCT data collection point Standard national template of content Permits assessment of staffing levels at each site. Precursor to transfer from one site to another. Antiviral medicines Not on FP10s Most via National Pandemic Flu Line Service Unique Reference Number (URN), needed to obtain antivirals from a local „collection point‟. Collecting Antivirals Flu Friends A nationwide campaign Collect antiviral drugs from PCT collection point centres Security measures will be in place no unauthorised or duplicate access to antivirals. Rebuilding, restoring and rehabilitation Gradual Return to normality over months Exhausted GPs and staff surprised at feeling unwell at this point. Recuperation time Mass vaccination campaign, could put added pressure on primary care Questions?