Current ED Swine Flu plan:

Patients with URI symptoms are immediately isolated.  If they can't go into a room, they will be placed in the hallway at the very end of our ED (between our current acute area and what will be CPEP/Peds ED).  As much as possible, we will use the rooms along the hallway between critical care and acute.  These 5 rooms (one in CC and 4 in acute) are all negative pressure rooms. We will attempt to keep at least one room free at all times.  We will attempt to use the CC room for such patients as well, unless that room is unavailable because of CC patients.  Peds patients will continue to be seen in peds.

The next step:

If the volume grows substantially, WE WILL REOPEN LEVEL 5, and see all URI patients upstairs. This will mean ADDITIONAL COVERAGE as needed.

WHO should see these patients?  It has been recommended that these patients be seen by as few health care providers as possible.  Students should not be seeing such patients.  It would be simplest for the attending to see these patients, but if a resident is available and an attending is not, then the resident should see the patient.

  1. Remember that the CLASSIC clinical picture of "flu" is a quite ill patients with fevers, URI symptoms, and quite striking myalgias.  I was taught (and I think this is VERY relevant teaching in the coming days) that if a patient presents with these classic combination of symptoms and you are pretty clear that it's influenza, YOU WILL BE RIGHT 50% OF THE TIME.  Some argue that this is good enough to clinically decide to treat, if you believe that treatment is important.
     

  2. The "quick test" for flu is 50% sensitive (i.e. will MISS 50% of true cases) and is 95% specific (1 in 20 positive tests are not positive for the disease). The "quick test" takes 2 hours.  THE TESTS WE SEND TO THE LAB ARE SUBSEQUENTLY SENT OUT TO ANOTHER LAB FOR CULTURE.  THESE RESULTS ARE AVAILABLE SEVERAL DAYS LATER.

 

Recommendations:
Symptom Sign Action
Patient with URI symptoms No fever, mild or moderate illness Wish them well and send them on their way
Patients with URI symptoms PLUS history of fever, or fever in ED.  Accept "shaking chills" as equivalent With history of high-risk exposure
(e.g. just got back from Mexico City or Queens College)		 Send a quick test. Consider treatment with Tamiflu or Relenza.
Without history of high-risk exposure Mild to moderate illness - don't test.  Don't treat unless you feel compelled to.
Severe disease, or you really think this is classic flu:  Test.  Treat.
Sick enough to be hospitalized: Test.  Treat.  Consider the test to be sent out to Wadsworth. (You'll have to fill out a form and get permission from Suffolk County DOH)
If this is a concern with an infant less than 1 year old, Peds ID has asked that they be called. 
For >1 y.o., follow the suggestions outlined here.

 

Testing:

In general, you don't HAVE to test patients you're seeing and discharging; the CDC and DOH are being very vague on the issue of testing in those patients not sick enough to be admitted to the hospital.  If you do test, and don't want them to wait for the results, AND would not treat them unless the test is positive, then discharge them with a prescription, but tell them to fill it only if you call them with positive results.  Or have them call you.  Testing is NOT required to initiate treatment, if, in your judgment, you think it would be helpful.

Treatment:

Generally ONLY indicated if the illness is less than 48 hours. Some evidence of modest help up to 72 hours in patients with comorbid conditions, so you can fudge on this.  So indications could be summed up as:

  1. Positive test, less than 48 (?72) hours - treat
     

  2. Negative test, or untested, but you really think this is the flu + 48 hr (or 72) - treat
     

  3. One option for everyone with MILD illness is no treatment at all, regardless

            Note: treatment costs around 40-50 bucks. CVS Pharmacy on Rte 347 at Old Town Rd. is the repository for ALL of the CVS Pharmacy Tamiflu.

What about YOU?

PROTECT YOURSELF.   The recommendations are for a full dress up with eye shield, N95mask, gown.

Other recommendations (from the SARS epidemic). No ties. No rings (on fingers). Clipped nails.

  1. Low risk chest pains - as much as possible, don't bother admitting these patients.  If it's after CTCA hours, hold the patient until the am, scan them from the ED, and send home the overwhelming majority who end up negative.  THIS KEEPS AN INPATIENT BED FREE FOR SICKER PATIENTS, AND ALLOWS THE MEDICAL ATTENDINGS TO FOCUS ON OTHER PATIENTS TO GET THEM OUT OF THE HOSPITAL QUICKER.
     

  2. Once it's clear what a patient needs, do not tolerate delays. Although we must always operate with grace and tact in enforcing rules and pushing flow, we cannot let patients sit endlessly in the waiting room.  As a corollary, complain intelligently.  It is helpful to detail the problems you're having with CPOE or pharmacy, etc. etc.
     

  3. We must work together as a team to do absolutely everything we can to see patients in a timely fashion in the face of rather extraordinary challenges.

  1. To simplify matters, the criteria for IC will NOT change from shift to shift, and day to day, depending on the desires of the particular attending.
     

  2. If one area is overloaded and another not, THE CHARGE NURSE IS EMPOWERED TO INCREMENTALLY REDISTRIBUTE PATIENTS, as safety allows, to areas where that given patient is not normally seen. The charge nurse will be doing this SOONER rather than LATER.