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H O S PI T AL S U L T AN AH N U R Z AH I R AH K U AL A TE R E N G G AN U INFLUENZA PANDEMIC PLAN OF ACTION 1. INTRODUCTION

There is a growing concern regarding the potential and the imminent threat of an influenza pandemic which could have the most devastating consequences. Hospital Sultanate Nur Zahirah prepared this plan of action in line with the National Influenza Pandemic Preparedness Plan. 1.1 Purpose:

The purpose of this plan of action is to facilitate an organized, coordinated and effective hospital preparedness and response in the event of an influenza pandemic. The plan provides a framework for preparedness and response by hospital. 1.2 General Objectives:

This action plan is to provide a preparedness and response plan for influenza pandemic to ensure rapid, timely and coordinated interdepartment actions in reducing the morbidity, mortality, social and economic disruption. 1.3 Specific Objectives: a. b. c. d. e. f. g. h. To establish interdepartment collaboration and cooperation To develop hospital staff awareness & educational programmes through training and other means on influenza To provide optimal medical care and support maintenance of essential services To provide recommendation for antiviral drug therapy & prophylaxis & to avoid inappropriate use of them To prepare necessary measures to prevent the spread of the disease. To facilitate the timely access to and supply of influenza vaccines and antiviral drugs during an outbreak To made specific recommendations and strategies for influenza immunization for the high risk groups and those in the essential services To communicate effectively with the state health department, public, health care providers, health professionals, stack holders, community leaders and the media

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MEDICAL STRATEGIES IN THE MANAGEMENT OF PANDEMIC INFLUENZA The Medical Strategy is to concentrate PI activities in Hospital Sultanah Nur Zahirah, Kuala Terenganu. All ill patients will be treated in HSNZ. 1. Health System Infrastructure Hospital Sultanah Nur Zahirah will be used as the fron tline for triaging and managing patients with suspected, probable or confirmed Pl. Initially all suspected PI cases will be treated in HSNZ. Any spillover will then be admitted to Hospital Hulu Terengganu(HHT). HSNZ will receive ill patients requiring ICU care from other triage centers in the State. In Phase 4 & 5 (Surge capacity) -- Hospital Hulu Terengganu will, Hospital Setiu and Hos pital Du ngu n wil l be as s igned to pro vid e treatm ent f or PI c ases due to the expected large number of patients. In Phase 6 -- the other hospitals will have to allocate about 10% of their current bed strength for suspected PI cases. 2. Isolat ion Facilities 2.1 Hospital Sultanah Nur Zahirah Is olatio n W ar d has been id entif ied as m ain ward f or adm is s ion. Su s pec ted PI patients and probable PI patients will be admitted to Isolation Ward. W hen the isolation beds are full, stable patients will be referred to Hospital Hulu Terengganu. Wad Isolation Negative pressure room will be used for ventilated cases. T ota l B ed c a pac i t y in HS NZ ar e 20 b eds . Is o la t io n war d has 4 is o l at i on r o om equipped with negative pressure room ventilation system and 16 bed for cohorted patient. 2.1.1 Critical Care in Hospital Sultanah Nur Zahirah The first 2 patients that require ventilation will go into the negative pres sure rooms in Isolation Ward . Subsequently, the ICU (Intensive Care Unit) will be emptied to cater for another 3 to 8 patients.. The next 9 to 20 patients will be ventilated in other critical care unit such as CCU and . Burns Unit. If the number of PI patie nt increase and more then 20, patients will be ventilate in open ward.

Table 1: Response to care of patients on ventilator in HSNZ

Estimated no of Ventilated Location Patients Designated 2 area with isolation facility General ICU 3-8 ·

Response

· · 9-20 Other critical care units eg. CCU · · >20 Open ward · ·

Deploy intensive care team to isolation ward to provide care Once exceeds capacity for ventilation, admit patients to ICU Stop elective surgery that requires ICU bed Transfer non-avian flu patients to other critical care areas in the hospital or non designated hospitals Once exceeds capacity for ventilation, admit patients to other critical care units Deploy ventilators from others hospital within state Transfer non-avian flu patients to non designated hospitals Once exceeds capacity for ventilation, convert a ward to ventilate patients Deploy ventilators from others states MOH to purchase/lease ventilators from companies Deploy staff from other wards Further emergency planning required Open more wards, deploy staff from other hospitals.

2.2 District Hospital Five other district hospitals in the state will response in order of prioritization if the need arises. All these hospitals will accommodate suspected/probable PI patients as according to bed capacity. The table below indicates the names of hospitals and the bed capacity. Table 2: List of Hospitals to be activated during the Pandemic Influenza (in the order of prioritization) BED CAPACITY (Phase 4 & 5)

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No. Hospital 1. Hospital Hulu Terengganu 2. 3. 4. 5. Hospital Setiu Hospital Dungun Hospital Besut Hospital Kemaman

Bed Capacity 20 20 20 20 20

TOTAL

100

3.

Personnel

3.1 Dr Norhaya bt Mohd Razali, a Consultant Respiratory Physician and Dato' Dr Jimmy Lee Kok Foo is Consultant Pediatrician from Hospital HSNZ will lead the team in managing Influenza cases. 3.2 Specialists have been appointed as PI Specialist and can be contacted at any time:-

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Dr. Ahmad Kashfi bin Abd. Rahman Dr. Sharifah Huda Engku Alwi Dr.Hasaruddin Ridzal Hanafi Dr. Aisai bin A. Rahman Dr. Nik Azman Nik Adib

-Infectious Disease Physician HSNZ -Paediatrician HSNZ -Pediatrician HSNZ -Consultant Anaestesiologist HSNZ -Anaestesiologist HSNZ

3.3 All staff working in the isolation ward will be given thermometers to chart and monitor their temperature twice daily and if febrile to report to the Ward sister-in-charge for further management.

Committee (HIPC) 4.1 An Operations Room will be activated at Phase 4 of PI by Hospital Director on the advice of the Terengganu State Health Director. (Refer Appendix 1) 4.2 HSNZ Influenza Pandemic Committee: Chairman: Hospital Director Members Hospital Deputies Heads Department of Medical, Heads Department of Pediatrics, Heads Department of Anaesthesia, H e ad s De pa r t m e nt of A &E Heads Department of Radiology Heads Department Pathology Heads Department of Pharmacy Head Department of Public Health Chief Matron, Chief Medical Assistant, Sister of Infection Control Unit, Ambulance and Hospital Support Service. Its role would be to: coordinate all activities provide and monitor all information determine additional resources needed Communication with State Influenza Pandemic Committee and State Operation Room Communication with Health District Office 4.3 HOR will notify suspected cases to District Operations Room (DOR). 4.4 Daily census of admissions and discharges will be sent to DOR by 12 noon and to the state Operations Room by 2 pm. 4.5 Names of key personnel, house telephone, hand-phone & fax no. must be available immediately. 5. Triage Hospital will set up a special PI counter outside / in front of A&E to screen for suspected PI patients. Special tents or vacated car/ambulance parking area can be used. This PI counter will be manned by dedicated staff. Signage or banners will be posted in front of A&E to inform the public. All patients with symptoms of PI will be straight away channeled to the PI counter without going to the main registration A&E counter to minimize contact with other patients.

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Any suspected PI cases should be noted to a specialist (Physician/Paediatrician). The steps listed are to be followed on diagnosing a suspect or probable PI case:. 6. Health Care Workers wears PPE Give patient 3ply surgical mask Give all patients in proximity 3 ply surgical mask Isolate patient Consult Physician/ Pediatrician Inform A & E dept and HOR If patient is stable, direct them to OPD/A & E designated triage If patient is ill, inform medical MO

Admission criteria All suspected PI cases will be admitted in Hospital Sultanate Nur Zahirah. All suspected cases of PI must be notified to the District Health Office and State Health Department. Asymptomatic household contacts or other close contacts of the case will be quarantined at home. In phase 6 only those with co-morbidities and complications will be admitted. All children younger than 2 years should be considered for admission regardless of co-morbidities and complications. Ambulance service Each district will allocate a dedicated ambulance for the transfer of patients to designated hospital. The ambulance will be from the hospital unless the PI goes into phase 5 and 6 (Refer to contingency plan by the state). Cases will be fetched from Health Centers and private health care facility by this dedicated ambulance. The ambulance will be decontaminated at the end of each trip at the designated hospitals (Refer to Appendix 3d). When sending patients to the designated hospitals, the accompanying staff can sit in the front seat of the ambulance if the patient is stable. The staff to accompany the patient will be from the referral center. Nursing Process Nursing process has been modified to decrease exposure to PI patients without compromising their care. The use of intercom for communication between patient and staff is encouraged. Nursing staff will work in 3 shifts. (Refer to Appendix 2) Laboratory Response All necessary laboratory investigations should be carried out at designated hospitals and under full PPE only .Staffs taking or handling specimens should be well informed. All safety aspects should be adhered. (Refer Appendix 5) Radiological Procedures Only necessary radiological procedures should be done. A dedicated portable X-Ray machine should be placed at the isolation ward. All staffs are to take precautionary steps during procedure. (Refer to Appendix 4)

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Mental health support will be given to staffs and families of patients affected during the pandemic. Activities will be coordinated by the State Psychiatrist. (Refer to Appendix 8) 12. Security and Visitors All isolation facilities will be cordoned off. Visitors will be kept to a minimum. Communication with their family members will be by telephones and hand phones. Death Hospital Operations Room and the mortuary staff will be informed. The last office of confirmed cases will follow SOP of infectious cases. Post mortem examination of suspected cases will be done in Hospital Tengku ampuan Afzan (HTAA). Unclaimed bodies sent to HTAA need not be sent back to the referring hospitals. Instead they can be buried by HTAA. Staff handling corpse must use full PPE. ( Refer to Appendix 9: Guidelines For Handling Dead Bodies With Suspected /Probable Pandemic Influenza). Personal Protective Equipment and Infection Control Training (Refer Appendix 3 and 3b) The training for staff will be coordinated by Infection Control Unit in the respective hospital. A core team of trainers led by the infection control nurse has been identified in each hospital. Training should also involve the dental and hospital support service staff. These training will include the use of N95 mask, glove, gown and shield. A training module has already been created to standardize training. This module also includes Basic training on the management of ill and ventilated patients. General knowledge on PI Preparing for the pandemic General Infection control practices Cough etiquette The training on gowning and degowning procedures will be repeated during the epidemic. 15. Infection Control Policies Infection control policies (decontamination, waste disposal, cleaning) will follow the guidelines from NIPPP. In cohort nursing each bed is to be considered as one isolation room. At the end of each examination the outer layer of apron and glove will be taken off and discarded in a yellow bin. A fresh layer will be put on before attending the next patient. Yellow bin will be made available at the foot of every bed.

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The distance of doctor to the patient during history taking will be 6 feet away. Auscultation will be done from the back of the patient while ensuring at the same time the face of the patient must be in the opposing direction of the doctor. Phones in the triage area will be covered with plastic which is discarded after every patient. Fax machines will be made available (where possible) in order to minimize transmission of the novel virus (e.g via handling case note etc). Patient's notes can be sent to various locations via fax. If fax machine is not available, case notes can be transferred in a plastic bag. (Refer to Appendix 3) 16. Stockpiling of consumables HSNZ required to stockpile consumables for the epidemic. consumables will include all PPE and essential drugs. Stockpile for HSNZ is for 50 patients for 2 weeks. The calculation of PPE stockpile is based on I staff will have 3 encounters with PI patient per shift. Assuming there are 3 staff per shift and there are 3 shifts per day, the total sets of PPE required for 50 patients for 2 weeks will be 3 x 3 x 3 x 50 x 14= 18900 sets. Stockpiling of antiviral drugs will be coordinated by Ministry of Health. This will be released when required. HSNZ will collect the antiviral drugs from Integrated Store in HSNZ. 17. Risk Management of staff handling PI patient A register of staff handling PI patients will be created. Data required will include identification data and the dates when they start and stopped nursing/ handling the patients. The number of staff handling the patient will be kept at a minimum. Staff will monitor their body temperature twice a day. If fever develops within one month of handling the patients, the staff should see the physician in charge. This staff will be taken out of the team and treated as suspect. Suspected staff will not be cohorted with other patients. They should be treated in a single isolated room. (Refer to Appendix 10 / Format 1 & 2 ) Further notification to the Health Office will be required for contact tracing. The Hospital Director should also be notified. Staff who have been in contact with PI patients can come back to work in the same ward. However this staff will be quarantined in the nurses' hostel. 18. Media Communication All staff will refrain from talking to the media All press information release will be coordinated at MOH level.

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