FAQ’s for Emergency Departments in Epidemic or Pandemic Influenza Outbreaks

May 6, 2009
11:01 AM ET

ACEP is identifying information to help you manage the current outbreak of H1N1 influenza. If you have questions or best practices to share, click here.

H1N1 (Swine Flu) Resources and Updates

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  1. Definitions
  2. Presentation, Triage and Waiting
    1. How can we identify which patients we should be concerned about?
    2. What should happen at triage during the outbreak?
    3. What provisions should we make to our waiting areas to avoid contaminating other patients?
    4. Is it permissible under EMTALA to triage stable patients with suspected cases of swine flu to an alternative site for evaluation?
  3. Care in the Emergency Department - Examination, Testing and Disposition
    1. Should I test patients with the rapid laboratory test or a point of care test?
    2. When should a nasal swab test be sent to CDC?
    3. Who is responsible for notifying the patient of the test results?
    4. What are indications for admission for suspected cases?
    5. Which patients should be offered oseltamivir (Tamiflu®) or zanamivir (Relenza®)?
    6. Are there special recommendations for the use of antivirals in children?
  4. Staff Considerations
    1. What are the most important considerations for infection control?
    2. Are N95 respirators required for health care providers, or are simple facemasks okay?
    3. How often should N95 respirators be changed?
    4. Are there recommendations for monitoring the health of the medical workforce?
    5. What about healthcare personnel who are sick?
    6. Are there special concerns for pregnant health providers?
  5. Advice to Patients
    1. Patient information - sample language

  1. Definitions for this document  

"Influenza-like Illness" (ILI) is defined as fever (temperature of 100ºF [37.8ºC] or greater) and a cough and/or a sore throat in the absence of a KNOWN cause other than influenza.

"Swine Flu" means the novel H1N1 viral disease identified by the CDC in 2009 as causing the outbreak in Mexico and the U.S. It is also referred to as "swine-origin influenza virus" (S-OIV) or the "Novel 2009 H1N1 virus."

A "suspected case" of swine flu infection is defined as a person with acute febrile respiratory illness with onset

  • within 7 days of close contact with a person who is a confirmed case of S-OIV infection, or
  • within 7 days of travel to community either within the United States or internationally where there are one or more confirmed cases of S-OIV infection, or
  • resides in a community where there are one or more confirmed cases of S-OIV infection. This information changes daily. Statewide information is available at http://cdc.gov/h1n1flu/. You should establish a link with your local health director for this information.

A "probable case" of swine flu infection is defined as a person with an acute febrile respiratory illness who is positive for influenza A, but negative for H1 and H3 by influenza reverse-transcription polymerase chain reaction test (RT-PCR).

A "confirmed case" of swine flu infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed swine origin influenza virus (S-OIV) infection at CDC by real-time RT-PCR or viral culture.

  1. Presentation, Triage and Waiting

Q: How can we identify which patients we should be concerned about?

A: First, determine the prevalence of the swine flu in your community and that of other acute febrile illnesses, such as late seasonal flu. This information should be available from your state health department or local health department director. Regardless of where you practice, any patient with fever and acute flu-like symptoms should be assessed if they meet the criteria for a "suspected case."

Q: What should happen at triage during the outbreak?

  1. Healthcare personnel should always observe Droplet Precautions (gloves, gown, mask and eye protection) in addition to Standard Precautions when examining any patient with symptoms of acute respiratory infection. This includes triage personnel in close proximity (within 6 feet).
  2. Triage personnel examining or coming in close contact with a suspected case of swine flu should wear a fitted N95 (or greater) respirator and should wash hands thoroughly between each patient.
  3. Screen patients with flu-like illness complaints using the suspected case criteria. Clinicians should suspect swine-origin influenza A (H1N1) in any person with an acute febrile respiratory illness who:
    • Have had close contact with a person who has a confirmed case of swine flu, or  
    • Has traveled to a community in the United States or internationally where there are one or more confirmed swine-origin influenza cases, or 
    • Resides in a community where there is one or more confirmed swine-origin influenza A (H1N1) cases.

Source: CDC
http://www.cdc.gov/h1n1flu/investigation.htm
http://www.cdc.gov/h1n1flu/identifyingpatients.htm  

  1. For suspected cases, the following considerations apply, based on the patient's vital signs, and respiratory status:
    1. Patients not requiring oxygen supplementation should be fitted with a surgical mask to control droplet spread. [see additional comments about waiting room, below]
    2. Patients requiring supplemental oxygen should be triaged to a private room with a door.
    3. Patients requiring respiratory procedures such as nebulizer treatments, suctioning, sputum induction or intubation should be triaged to an airborne infection isolation room.

Source: CDC
http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm  

  1. Waiting Room: Patients who must wait to be seen should NOT be placed in close proximity to other patients (within 6 feet). If this is not physically possible, patients without respiratory symptoms should be sent to a separate area.

Q: What provisions should we make to our waiting areas to avoid contaminating other patients?

A: Separate ILI patients from the general population: During the outbreak, waiting areas should be configured to separate cases of influenza-like illness (ILI) from the general ED population of patients with injuries and other illnesses. EDs that are seeing large numbers of ILI patients may choose set up a temporary covered area outside of the ED in open air. Experience during the SARS epidemic demonstrated that this can be an effective strategy where the climate permits.

Visitors or family members who have been in close contact with a confirmed case of swine flu are at risk for transmission of the virus. A patient may be infected with the virus and contagious for a day or more before the onset of symptoms.  Visitors may be offered a standard mask to reduce droplet spread and be instructed by healthcare personnel on its use. They should also be instructed on frequent hand washing and limiting movement within the ED and hospital.

Q: Is it permissible under EMTALA to triage stable patients with suspected cases of swine flu to an alternative site for evaluation?

A: If the patient is not severely ill and does not require the resources of the emergency department, sending the patient to an alternative facility, such as a clinic or a temporary treatment area, is consistent with EMTALA regulations. Using an alternative site for the medical screening exam (MSE) may be desirable if substantial numbers of patients with ILI complaints are presenting to the primary ED. If the physical limitations of your waiting areas are such that other patients might be inadvertently exposed to swine flu, early implementation of an alternative examination area may be warranted.

If the patient is to be directed to an alternate site for care:

  • The patient's vital signs, history and co-morbidities should not warrant immediate attention in the emergency department.
  • The alternative site should be designated by the hospital as the site where the MSE is to be performed for patients with ILI.
  • The alternative MSE site should be equipped to screen patients for the disease and to ensure they receive an appropriate examination, test procedures, treatment, and appropriate disposition.
  • The alternative site should be on the hospital premises or in close proximity. Patients should not be required to transport themselves.
  • The alternative site should employ the same infection control precautions that would be used in the primary emergency department.

Under these conditions EMTALA would be satisfied, since the MSE would be done at the alternative site on behalf of the hospital. The duty to perform the MSE rests with the hospital, but the hospital can discharge its duty in any location that is able to reasonably determine if an Emergency Medical Condition exists. This does not necessarily have to be done in the hospital's primary emergency department. 

  1. Care in the Emergency Department - Examination, Testing and Disposition

Q: Should I test patients with the rapid laboratory test or a point of care test?

A: Data are not yet available on the use of rapid influenza diagnostic tests in patients with novel H1N1 virus infection. It is reasonable to assume that rapid diagnostic tests that detect influenza A viral nucleoprotein antigen can detect novel H1N1 flu infection in respiratory specimens. However, the sensitivity and specificity of the different commercially available rapid tests is not yet known for this novel virus. CDC has received anecdotal reports of false positive and false negative results. Clinicians may consider using rapid diagnostic tests as part of their evaluation of patients with signs and symptoms compatible with influenza, but the results should be interpreted with caution. Confirmation of novel H1N1 flu infection can only be made by RT-PCR or viral culture. A test that is negative for H1 does not rule out novel H1N1 "swine flu" disease.
Source: CDC
http://www.cdc.gov/h1n1flu/guidance/rapid_testing.htm  

Many physicians use rapid influenza testing to guide their use of antiviral medications. The Novel 2009 H1N1 virus has thus far been sensitive to both oseltamivir (Tamiflu®) and zanamivir (Relenza®), although the 2009 seasonal flu has shown resistance to oseltamivir (Tamiflu®). Since rapid flu tests cannot be used to discriminate between the seasonal and the novel strains, patients positive for influenza A may or may not respond to oseltamivir (Tamiflu®).

Q: When should a nasal swab test be sent to CDC?

A: Testing is not indicated for patients with mild illness. Patients presenting to providers participating in the U.S. Outpatient Influenza-like Illness Surveillance Network (ILI Net) who meet the case definition of influenza-like illness (ILI) will be tested.
However, if the patient with a suspected, probable or confirmed case of swine flu is severely ill or at high risk of complications (see below) clinicians should obtain an upper respiratory specimen, such as a nasopharyngeal swab or wash, or nasal wash/aspirate, or tracheal aspirate.

Specimens should be submitted to your state's public health laboratory. Interim guidance on specimen collection ,processing, and testing for patients with suspected swine-origin influenza A (H1N1) virus infection can be found at: http://www.cdc.gov/h1n1flu/specimencollection.htm

Q: Who is responsible for notifying the patient of the test results?

A: The CDC has not issued guidance about patient follow-up for a positive test. It remains the responsibility of the treating physician/institution to notify the patient of the results.

Q: What are indications for admission for suspected cases?

A: There are insufficient data to determine who is at higher risk for complications of the novel H1N1 swine flu infection. At this time, the same age and risk groups who are at higher risk for seasonal influenza complications should also be considered at higher risk of complications from swine flu.

  • Children less than 5 years old;
  • Persons aged 50 years or older;
  • Children and adolescents (aged 6 months–18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection;
  • Pregnant women;
  • Adults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders;
  • Adults and children who have immunosuppression (including that caused by medications or HIV);
  • Residents of nursing homes and other chronic-care facilities
Q: Which patients should be offered oseltamivir (Tamiflu®) or zanamivir (Relenza®)?

A: Antiviral treatment should be considered for confirmed, probable or suspected cases of swine-origin influenza A (H1N1) virus infection. The Novel 2009 H1N1 virus has thus far been sensitive to both oseltamivir (Tamiflu®) and zanamivir (Relenza®). Treatment of hospitalized patients and patients at higher risk for influenza complications should be prioritized. Evidence of benefit is greatest if treatment is started within 48 hours of symptom onset.

Anti-viral drugs are less effective when given 48 hours after the onset of symptoms; thus, many patients presenting to the ED will already be beyond the time window for effectiveness and should not be offered the drug for mild illness.

See: http://www.cdc.gov/h1n1flu/recommendations.htm

Q: Are there special recommendations for the use of antivirals in children?

A: Antiviral treatment with oseltamivir (Tamiflu ®) or zanamivir (Relenza ®) is recommended for children with confirmed or probable H1N1 swine flu infection. Empiric antiviral treatment is also recommended for children with suspected cases of swine influenza A (H1N1) virus infection with severe illness. Antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of symptoms.

In children 1 year of age or older, doses recommended for treatment of H1N1 swine flu infection are the same as those recommended for seasonal influenza. The following dosing table was extracted by the CDC from IDSA dosing guidelines:

 

Agent, group

Treatment

Chemoprophylaxis

Oseltamivir

Children (age, 12 months or older), weight:

15 kg or less

60 mg per day divided into 2 doses

30 mg q day

15-23 kg

90 mg per day divided into 2 doses

45 mg once per day

24-40 kg

120 mg per day divided into 2 doses

60 mg once per day

>40 kg

150 mg per day divided into 2 doses

75 mg once per day

Zanamivir

Children

Two 5-mg inhalations (10 mg total) twice per day (age, 7 years or older)

Two 5-mg inhalations (10 mg total) once per day (age, 5 years or older)

Children less than one year of age are at higher risk for complications associated with seasonal human influenza virus infections compared to older children, and the risk of influenza complications is especially high for children less than 6 months of age. It is not known whether infants are at higher risk for complications associated with H1N1 swine flu infection compared to older children. But because infants typically have higher rates of morbidity and mortality from influenza compared to healthy older children, infants with H1N1 swine flu infections may benefit from treatment using oseltamivir. 

Limited safety data on the use of oseltamivir (Tamiflu ®) or zanamivir (Relenza ®) is available from children less than one year of age. Neither drug is licensed for use in this age group, but the FDA has issued an Emergency Use Authorization (EUA) to allow the use of oseltamivir (Tamiflu ®) to treat and prevent for children younger than 1 year.

Source: FDA http://www.fda.gov/bbs/topics/NEWS/2009/NEW02002.html  

Dosing for these children is age-based.

Age

Recommended treatment dose for 5 days

<3 months

12 mg twice daily

3-5 months

20 mg twice daily

6-11 months

25 mg twice daily

Source: CDC
http://www.cdc.gov/h1n1flu/childrentreatment.htm

As usual, physicians are reminded that acetaminophen or NSAIDs should be use for fever. Due to the risk of Reye’s Syndrome, aspirin or aspirin-containing products (e.g. bismuth subsalicylate – Pepto Bismol ®) should not be administered to any confirmed or suspected ill case of swine influenza A (H1N1) virus infection aged 18 years old and younger.

  1.  Staff Considerations:

Q:  What are the most important considerations for infection control?

A:  The use of proper personal protective equipment, rigorous hand washing after each patient contact, respiratory isolation of cases undergoing respiratory procedures,  environmental cleaning, availability and use of hand sanitizer, and good ventilation.

Q. Are N95 respirators required for health care providers, or are simple facemasks OK?

A. All healthcare personnel who enter the rooms of patients in isolation for swine influenza should wear a fit-tested disposable N95 respirator or equivalent (e.g., powered air purifying respirator) and should be donned upon room entry.
Note: This recommendation is stronger than current infection control guidance for seasonal influenza, which recommends that healthcare personnel need only surgical masks for patient care.

Source: CDC
http://www.pandemicflu.gov/plan/healthcare/maskguidancehc.html  

Q: How often should N95 respirators be changed?  

A: Four N95 masks should be used per employee per 8 hour work shift.  An N-95 mask can be used for up to 2 or 3 hours, as long as it is remains in good condition and is not contaminated. If the respirator is damaged, soiled, or wet, or if breathing becomes difficult, you should remove the respirator, discard it properly, and replace it with a new one. To discard your N95 respirator safely, assume it is contaminated, and dispose of it in a biohazard container. Wash your hands immediately after handling a used respirator.

To control costs, institutions may wish to purchase reusable respirators that can be sterilized and may be useful for the duration of an influenza epidemic.

Source: CDC - NIOSH
http://www.osha.gov/dsg/guidance/stockpiling-facemasks-respirators.html  

Q: Are there recommendations for monitoring the health of the medical workforce?

A: In communities where swine influenza A (H1N1) virus transmission is occurring, healthcare personnel should be monitored daily for signs and symptoms of febrile respiratory illness. Those who develop these symptoms should be instructed not to report to work, or if at work, should cease patient care activities and notify their supervisor and infection control personnel.

In communities without swine influenza A (H1N1) virus transmission, healthcare personnel working in areas of a facility where there are patients being assessed or isolated for swine influenza infection should be monitored daily for signs and symptoms of febrile respiratory infection. This includes healthcare personnel working in outpatient settings or the emergency department. Those who develop symptoms should be instructed not to report to work, or if at work, to cease patient care activities and notify their supervisor and infection control personnel.

Healthcare personnel who do not have a febrile respiratory illness may continue to work. Asymptomatic healthcare personnel who have had an unprotected exposure to swine influenza A (H1N1) also may continue to work provided that they are started on antiviral prophylaxis.

Source: CDC
http://www.cdc.gov/h1n1flu/recommendations.htm.

Q: What about healthcare personnel who are sick?

A: Healthcare personnel should not report to work if they have a febrile respiratory illness. In communities where swine influenza virus transmission is occurring, healthcare personnel who develop a febrile respiratory illness should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.

In communities without swine influenza virus transmission, healthcare personnel who develop a febrile respiratory illness and have been working in areas of the hospital where swine influenza patients are present should be excluded from work for 7 days or until symptoms have resolved, whichever is longer.

In communities where swine influenza virus transmission is not occurring, healthcare personnel who develop febrile respiratory illness and have not been in areas of the facility where swine influenza patients are present should follow their facility guidelines on returning to work.

Source: CDC
http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm  

Q: Are there special concerns for pregnant health providers?

A: Pregnant women who will likely be in direct contact with patients with confirmed, probable, or suspected influenza A (H1N1) (e.g., a nurse, physician, or respiratory therapist caring for hospitalized patients), should be assigned to lower-risk activities, such as staffing a telephone advice line. If reassignment is not possible, pregnant women should avoid participating in procedures that may generate increased small-particle aerosols of respiratory secretions in patients with known or suspected influenza.

Additional information is available at:
http://www.cdc.gov/h1n1flu/guidance/pregnant-hcw-educators.htm  

Guidance on pre-exposure and post-exposure chemoprophylaxis with antiviral agents, including for pregnant women can be found at: http://www.cdc.gov/h1n1flu/recommendations.htm

  1. Advice to Patients -sample language

If you live in an area where swine flu cases have been identified AND you are ill with fever with body aches, runny nose, sore throat, nausea, or vomiting or diarrhea, you might have the illness. Rather than going straight to the ER, you should contact your doctor or a health care help line for advice. Your health care provider will determine whether examination, influenza testing or treatment is needed, or whether you are better off resting at home.

While you are sick, you should stay home, ideally in a private room, and avoid contact with other people as much as possible.  This will help you to keep from spreading your illness to others. You should avoid public transportation and air travel, as well as any crowded area where you might spread your illness.  You should stay isolated for 7 days, or until you feel well.  Children may need to be isolated longer before they are allowed to go back to school and play with friends.

Patients who are ill and experience any of the following warning signs should come to the emergency department:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Confusion
  • Severe or persistent vomiting or inability to retain liquids

Children who have the following signs should be taken to the emergency department:

  • Fast breathing or trouble breathing
  • Bluish or gray skin color
  • Not drinking enough fluids
  • Not waking up or not interacting with parents
  • Being so irritable that the child does not want to be held
  • Flu-like symptoms improve but then return with fever and worse cough
  • Fever with a rash

If you have no symptoms of illness, you do not need to seek emergency care. If you do not have a fever or cough, treatment for swine flu is not necessary. If you have symptoms that would not ordinarily lead you to seek care in an emergency department you do not need to go. If you feel well or are only mildly ill, it is better to contact your doctor or a health advice line for information, rather than going to the emergency department.

Remember, many illnesses &ndash; including swine flu &ndash; can be unintentionally transmitted from person to person in a crowded public places.  If you are not sick, it is generally a good idea to avoid a crowded ER waiting room.  

The best way to avoid the spread of disease is to stay home until your symptoms subside.

If you want to learn more about swine flu, the Centers for Disease Control and Prevention (CDC) is maintaining up-to-date web site with useful information to the public. http://www.cdc.gov/h1n1flu/swineflu_you.htm  

This document was created for ACEP membership using information from the Centers for Disease Control and Prevention, selected state health department guidance, and expert opinions of the review team. The team was chaired by Dr. Jeff Runge. The reviewers were Dr. Andrew Bern, Dr. Robert Bitterman, Dr. Stephen Cantrill, Dr. Arthur Kellermann, Dr. Kristi Koenig, Dr. Gregory Moran, Dr. Andrew Sama, and Dr. Carl Schultz.

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