Swine flu clinical package for use when there are exceptionaldemands on healthcare services

These tools and pathways are for use only when highhealthcare demand leads to the need for strict hospitaladmission triage in affected areas.

IntroductionThis clinical package is for use in conditions of exceptional demand for healthcare services

THESE TOOLS AND PATHWAYS ARE FOR USE ONLY WHEN HIGH HEALTHCARE DEMANDLEADS TO THE NEED FOR STRICT HOSPITAL ADMISSION TRIAGE IN AFFECTED AREAS. They should not be used when emergency departments and acute admissions units areworking with their usual establishment of trained staff, and can operate their usual dailydecision pathways, including providing hospital beds for those requiring admission.

THE TOOLS ARE NOT INTENDED FOR THE ASSESSMENT OF PATIENTS ROUTINELYPRESENTING FOR THE DIAGNOSIS AND TREATMENT OF UNCOMPLICATED INFLUENZAAT AN EMERGENCY DEPARTMENT. These patients should be directed to use the NationalPandemic Flu Service, or to contact a primary care surgery or clinic.

As one or more pandemic waves affect different areas of the country, Primary Care Trusts,Ambulance Trusts and Acute Trusts may decide that they need to use these tools on anumber of occasions, depending on the local situation.

Most patients attending for triage will previously have had flu confirmed and treated inprimary care, and may already have been commenced on treatment for complications or forexacerbation of underlying conditions. A few patients will present with very severe onset offlu symptoms.

The tools and pathways in the Swine Flu Clinical package are intended to provide aframework for consistent decision-making when excessive demand is severely challengingthe capacity of healthcare services, staffing levels are depleted, and triage is being undertakenby staff who do not usually work in emergency departments or acute admissions units.

At such times, a ‘high bar’ will have to be applied to triage systems for hospital admission,meaning that only severely ill patients can be admitted. Patients who would have been caredfor in hospital under normal circumstances may therefore not be admitted. Furthermore,severe stress on facilities such as X-ray and imaging services, as well as urgent laboratoryinvestigations, will mean that clinical assessment and examination may be the main sourceof information for early triage.

The tools are therefore designed to provide extra safety measures for people who aremoderately unwell, but cannot be admitted to hospital at the time of triage. Safety measuresmay include the provision of empirical antibiotic treatment which would not be offered oninitial presentation with flu symptoms.

Where appropriate medical experience is available, and clinical judgements can be made, the individual patient’s pathway may be adjusted on the basis of an expert assessment.

Swine flu clinical packageDepartment of Health Gateway number: 12368

The Swine Flu Clinical Package contains five tools:

1 Swine Flu Paediatric Community Assessment Tool (Paediatric CAT)

2 Swine Flu Adult Community Assessment Tool (Adult CAT)

3 Community to Hospital Referral Form

4 Swine Flu Paediatric Hospital Pathways

5 Swine Flu Adult Hospital Pathways

It is accepted that not all healthcare and investigational facilities will be available at all times.The tools are designed to allow for this.

Community Assessment Tools

The Community Assessment Tools (CATs) have been developed to support front-linehealthcare professionals in deciding which children and adults are most likely to benefit fromhospital treatment in a flu pandemic. CATs provide a framework for consistent decision-making in a range of situations when resources are limited. CATs are not specific to flu, buttheir criteria address the most likely modes of critical illness arising from flu, or thecomplications of flu. The CATs have been developed by paediatric and adult expert ClinicalDevelopment Groups drawing on the nationally accepted clinical evidence that supports therecognition of severe illness. The relevant professional bodies nominated the DevelopmentGroups’ members.1 The Development Groups achieved consensus in a process supported bythe Department of Health.

The CATs are intended to be used by GPs and other regulated healthcare professionals(midwives, health visitors, school nurses, community nurses, ambulance crew, emergencydepartment nurses and doctors).

The CATs are locked documents (PDFs) and should not be altered except to change scale,e.g. to fit a pocket or para-bag.

NB: The CATs are for use for patients with acute feverish or flu-like illness; patients whoclearly need an alternative pathway (such as chest pain, stroke or acute abdomen) shouldfollow that pathway.

1 The following organisations nominated experts to the Paediatric (p) and Adult (a) Clinical Development Groups: The Royal College of General Practitioners (a, p), The Royal College of Paediatrics and Child Health (p), The Royal College of Physicians (a), The Royal College of Midwives (p), The Royal College ofNursing (a, p), The College of Emergency Medicine (a, p), Unite/The Community Practitioners’ and Health Visitors’ Association (p), The British MedicalAssociation (a, p), and The Directors of Clinical Care of UK Ambulance Trusts (a, p).

Community to Hospital Referral Form

Patients who meet referral criteria should be referred to the nearest general hospitalEmergency Department using the Community to Hospital Referral Form. The Community toHospital Referral Form is harmonised with the CATs and the hospital pathways to preventreferral loops. This form has been endorsed by the Royal College of General Practitioners andthe British Medical Association.

Hospital Pathways

The Hospital Pathways are based on those developed and adopted for use in NHS North West. The Emergency Department triage sections of the Hospital Pathways areharmonised with the CATs and Community to Hospital Referral Form to prevent referralloops. The Hospital Pathways are provided as templates in PDF format. The PDF template is the source document endorsed by the expert bodies as indicated on the document.

Adaptation of the PDF document should only be made with the authority of Trusts’medical directors to reflect individual Trusts’ policy decisions in accordance with theirclinical governance procedures.

This assessment tool should be used during severe and exceptional circumstances when surge demand for healthcare servicesleads to a need for strict triage. It will assist with deciding whether a sick febrile child with flu-like illness needs referral tothe nearest general hospital Emergency Department. Most children are expected to be managed in the community.

Respiratory failure, overwhelming gastroenteritis, shock, heart failure and encephalitis are the most likely modesof critical illness in children suffering from swine flu. Complications such as sepsis and meningitis may co-exist.

Criteria REFER CHILDREN TO THE NEAREST GENERAL HOSPITAL EMERGENCY DEPARTMENT IF THEYlabel PRESENT WITH ANY OF THE FOLLOWING:

A Severe respiratory distressLower chest wall indrawing, sternal recession, grunting, or noisy breathing when calm.

B Increased respiratory rate measured over at least 30 seconds.≥50 breaths per minute if under 1 year, or ≥40 breaths per minute if ≥1 year.

C Oxygen saturation ≤92% on pulse oximetry, breathing air or on oxygenAbsence of cyanosis is a poor discriminator for severe illness.

D Respiratory exhaustion or apnoeic episodeApnoea defined as a ≥20 second pause in breathing.

EEvidence of severe clinical dehydration or clinical shockSternal capillary refill time >2 seconds, reduced skin turgor, sunken eyes or fontanelle.

F Altered conscious levelStrikingly agitated or irritable, seizures, or floppy infant.

G Causing other clinical concern to their own GP or clinical teame.g. a rapidly progressive or an unusually prolonged illness.

Further information

l This tool is designed to support and empower all healthcare professionals working in difficultcircumstances with limited resources, but does not supersede a decision by an experienced clinicianabout whether, when or where to refer a child.

l The assessment applies to all children under 16 years old and is independent of any prior or existingmedical condition.

l Infants less than 2 months old with increased respiratory rate and sternal recession should bereferred promptly to the nearest hospital because they are at high risk of suffering severeillness or death.

l Fever alone is not used as a criterion for referral to hospital in children over 3 months of age, as it is apoor discriminator for severe illness.

l Difficulty in feeding indicates a need for assessment but is not by itself a good measure of severe illness.

l When referral is not indicated, a copy of the home care advice leaflet should be provided, withencouragement to call again should the child’s condition deteriorate.

l Every assessment should include a record of the time of assessment and time of onset of illness.Referrals must include the criteria label(s) to assist with the treatment of children on arrival at hospital.

The Swine Flu Paediatric Community Assessment Tool is endorsed by: The Royal College of General Practitioners,The Royal College of Paediatrics and Child Health, The Royal College of Nursing, The Royal College ofMidwives, The College of Emergency Medicine, The Directors of Clinical Care of UK Ambulance Trusts, The British Medical Association and Unite/The Community Practitioners’ and Health Visitors’ Association.

© Crown copyright 2009

Produced by COI for the Department of Health

295897 1p Sep 09

Swine flu paediatric community assessment toolFor use in all children under 16 years old in the community.

PAEDIATRIC

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PAED

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g se

vere

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whe

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s ne

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he n

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tmen

t. M

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ren

are

expe

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anag

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pir

ato

ry f

ailu

re,

ove

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elm

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ente

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itsel

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ice

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sho

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the

tre

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of c

hild

ren

on a

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edia

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l Col

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of

Paed

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ics

and

Chi

ld H

ealth

, Th

e Ro

yal C

olle

ge o

f N

ursi

ng,

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Roya

l Col

lege

of

Mid

wiv

es,

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Col

lege

of

Emer

genc

y M

edic

ine,

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Dire

ctor

s of

Clin

ical

Car

e of

UK

Am

bula

nce

Trus

ts,

The

Briti

sh M

edic

alA

ssoc

iatio

n an

d U

nite

/The

Com

mun

ity P

ract

ition

ers’

and

Hea

lth V

isito

rs’

Ass

ocia

tion.

©C

row

n co

pyrig

ht 2

009

Prod

uced

by

CO

I for

the

Dep

artm

ent

of H

ealth

2958

97 1

p Se

p 09

PAED

IATR

IC

This assessment tool should be used during severe and exceptional circumstances when surge demand for healthcare servicesleads to a need for strict triage. It will assist with deciding whether a sick febrile adult with flu-like illness needs referral tothe nearest general hospital Emergency Department. Most adults are expected to be managed in the community.

Respiratory failure, shock, heart failure and encephalopathy are the most likely modes of presentation in adultssuffering from severe infection.

Swine flu adult community assessment toolFor use in all adults aged 16 years or older in the community.

Criteria REFER ADULTS TO THE NEAREST GENERAL HOSPITAL EMERGENCY DEPARTMENT IF THEY label PRESENT WITH ANY OF THE FOLLOWING:

ASevere respiratory distressSevere breathlessness, e.g. unable to complete sentences in one breath. Use of accessory muscles, supra-clavicular recession, tracheal tug or feeling of suffocation.

B Increased respiratory rate measured over at least 30 seconds.Over 30 breaths per minute.

C Oxygen saturation ≤92% on pulse oximetry, breathing air or on oxygenAbsence of cyanosis is a poor discriminator for severe illness.

D Respiratory exhaustionNew abnormal breathing pattern, e.g. alternating fast and slow rate or long pauses between breaths.

EEvidence of severe clinical dehydration or clinical shockSystolic blood pressure <90mmHg and/or diastolic blood pressure <60mmHg.Sternal capillary refill time >2 seconds, reduced skin turgor.

F Altered conscious levelNew confusion, striking agitation or seizures.

G Causing other clinical concern to their own GP or clinical teame.g. a rapidly progressive or an unusually prolonged illness.

Further information

l The tool is designed to support and empower all healthcare professionals working in difficultcircumstances with limited resources but does not supersede a decision by an experienced clinicianabout whether, when or where to refer an adult.

l The assessment applies to all adults aged 16 years or over and is independent of any prior or existingmedical condition.

l Fever alone is not used as a criterion for referral as it is a poor discriminator for severe illness.

l Difficulty in self care indicates a need for assessment but is not by itself a good measure of severe illnessor need for hospital admission. Referral to a community-based support facility may be suitable.

l When referral is not indicated, a copy of the home care advice leaflet should be provided, withencouragement to seek medical advice again should the adult’s condition deteriorate.

l Every assessment should include a record of the time of assessment and time of onset of illness.Referrals must include the criteria label(s) to assist with the treatment of adults on arrival at hospital.

The Swine Flu Adult Community Assessment Tool is endorsed by: The Royal College of General Practitioners,The Royal College of Physicians, The Royal College of Nursing, The College of Emergency Medicine, The Directors of Clinical Care of UK Ambulance Trusts and The British Medical Association.

© Crown copyright 2009

Produced by COI for the Department of Health

295897 1p Sep 09

ADULT

This

ass

essm

ent

tool

sho

uld

be u

sed

durin

g se

vere

and

exc

eptio

nal c

ircum

stan

ces

whe

n su

rge

dem

and

for

heal

thca

rese

rvic

es le

ads

to a

nee

d fo

r st

rict

tria

ge.

It w

ill a

ssis

t w

ith d

ecid

ing

whe

ther

a s

ick

febr

ile a

dult

with

flu

-like

illn

ess

need

sre

ferr

alto

the

nea

rest

gen

eral

hos

pita

l Em

erge

ncy

Dep

artm

ent.

Mos

t ad

ults

are

exp

ecte

d to

be

man

aged

in t

he c

omm

unity

.

Res

pir

ato

ry f

ailu

re,

sho

ck,

hea

rt f

ailu

re a

nd

en

cep

hal

op

ath

y ar

e th

e m

ost

lik

ely

mo

des

of

pre

sen

tati

on

in

adu

lts

suff

erin

g f

rom

sev

ere

infe

ctio

n.

Swin

e fl

u a

du

lt c

om

mu

nit

y as

sess

men

t to

ol

For

use

in

all

adu

lts

aged

16

year

s o

r o

lder

in

th

e co

mm

un

ity.

Furt

her

in

form

atio

n

•Th

e to

ol is

des

igne

d to

sup

port

and

em

pow

er a

ll he

alth

care

pro

fess

iona

ls w

orki

ng in

diff

icul

t ci

rcum

stan

ces

with

lim

ited

reso

urce

s bu

t do

es n

ot s

uper

sede

a d

ecis

ion

by a

n ex

perie

nced

clin

icia

n ab

out

whe

ther

, w

hen

orw

here

to

refe

r an

adu

lt.

•Th

e as

sess

men

t ap

plie

s to

all

adul

ts a

ged

16 y

ears

or

over

and

is in

depe

nden

t of

any

prio

r or

exi

stin

g m

edic

alco

nditi

on.

•Fe

ver

alon

e is

not

use

d as

a c

riter

ion

for

refe

rral

as

it is

a p

oor

disc

rimin

ator

for

sev

ere

illne

ss.

•D

iffic

ulty

in s

elf

care

indi

cate

s a

need

for

ass

essm

ent

but

is n

ot b

y its

elf

a go

od m

easu

re o

f se

vere

illn

ess

orne

ed f

or h

ospi

tal a

dmis

sion

. Re

ferr

al t

o a

com

mun

ity-b

ased

sup

port

fac

ility

may

be

suita

ble.

•W

hen

refe

rral

is n

ot in

dica

ted,

a c

opy

of t

he h

ome

care

advi

ce le

afle

t sh

ould

be

prov

ided

, w

ith e

ncou

rage

men

tto

see

k m

edic

al a

dvic

e ag

ain

shou

ld t

he a

dult’

s co

nditi

on d

eter

iora

te.

•Ev

ery

asse

ssm

ent

shou

ld in

clud

e a

reco

rd o

f th

e tim

e of

ass

essm

ent

and

time

of o

nset

of

illne

ss.

Refe

rral

s m

ust

incl

ude

the

crite

ria la

bel(s

) to

ass

ist

with

the

tre

atm

ent

of a

dults

on

arriv

al a

t ho

spita

l.

The

Swin

e Fl

u A

dult

Com

mun

ity A

sses

smen

t To

ol is

end

orse

d by

: Th

e Ro

yal C

olle

ge o

f G

ener

al P

ract

ition

ers,

Th

e Ro

yal C

olle

ge o

f Ph

ysic

ians

, Th

e Ro

yal C

olle

ge o

f N

ursi

ng,

The

Col

lege

of

Emer

genc

y M

edic

ine,

Th

e D

irect

ors

of C

linic

al C

are

of U

K A

mbu

lanc

e Tr

usts

and

The

Brit

ish

Med

ical

Ass

ocia

tion.

©C

row

n co

pyrig

ht 2

009

Prod

uced

by

CO

I for

the

Dep

artm

ent

of H

ealth

2958

97 1

p Se

p 09

Cri

teri

aR

EFER

AD

ULT

S TO

TH

E N

EAR

EST

GEN

ERA

L H

OSP

ITA

L EM

ERG

ENC

Y D

EPA

RTM

ENT

IF T

HEY

la

bel

PRES

ENT

WIT

H A

NY

OF

THE

FOLL

OW

ING

:

ASe

vere

res

pir

ato

ry d

istr

ess

Seve

rebr

eath

less

ness

, e.

g. u

nabl

e to

com

plet

e se

nten

ces

in o

ne b

reat

h.

Use

of

acce

ssor

y m

uscl

es,

supr

a-cl

avic

ular

rec

essi

on,

trac

heal

tug

or

feel

ing

of s

uffo

catio

n.

BIn

crea

sed

res

pir

ato

ry r

ate

mea

sure

d ov

er a

t le

ast

30 s

econ

ds.

Ove

r 30

bre

aths

per

min

ute.

CO

xyg

en s

atu

rati

on

≤92

% o

n p

uls

e o

xim

etry

, b

reat

hin

g a

ir o

ro

n o

xyg

enA

bsen

ce o

f cy

anos

is is

a p

oor

disc

rimin

ator

for

sev

ere

illne

ss.

DR

esp

irat

ory

exh

aust

ion

New

abn

orm

al b

reat

hing

pat

tern

, e.

g. a

ltern

atin

g fa

st a

nd s

low

rat

e or

long

pau

ses

betw

een

brea

ths.

EEv

iden

ce o

f se

vere

clin

ical

deh

ydra

tio

n o

r cl

inic

al s

ho

ckSy

stol

ic b

lood

pre

ssur

e <

90m

mH

g an

d/or

dia

stol

ic b

lood

pre

ssur

e <

60m

mH

g.St

erna

l cap

illar

y re

fill t

ime

>2

seco

nds,

red

uced

ski

n tu

rgor

.

FA

lter

ed c

on

scio

us

leve

lN

ew c

onfu

sion

, st

rikin

g ag

itatio

n or

sei

zure

s.

GC

ausi

ng

oth

er c

linic

al c

on

cern

to

th

eir

ow

n G

P o

r cl

inic

al t

eam

e.g.

a r

apid

ly p

rogr

essi

ve o

r an

unu

sual

ly p

rolo

nged

illn

ess.

AD

ULT

This

ass

essm

ent

tool

sho

uld

be u

sed

durin

g se

vere

and

exc

eptio

nal c

ircum

stan

ces

whe

n su

rge

dem

and

for

heal

thca

rese

rvic

es le

ads

to a

nee

d fo

r st

rict

tria

ge.

It w

ill a

ssis

t w

ith d

ecid

ing

whe

ther

a s

ick

febr

ile a

dult

with

flu

-like

illn

ess

need

sre

ferr

alto

the

nea

rest

gen

eral

hos

pita

l Em

erge

ncy

Dep

artm

ent.

Mos

t ad

ults

are

exp

ecte

d to

be

man

aged

in t

he c

omm

unity

.

Res

pir

ato

ry f

ailu

re,

sho

ck,

hea

rt f

ailu

re a

nd

en

cep

hal

op

ath

y ar

e th

e m

ost

lik

ely

mo

des

of

pre

sen

tati

on

in

adu

lts

suff

erin

g f

rom

sev

ere

infe

ctio

n.

Swin

e fl

u a

du

lt c

om

mu

nit

y as

sess

men

t to

ol

For

use

in

all

adu

lts

aged

16

year

s o

r o

lder

in

th

e co

mm

un

ity.

Furt

her

in

form

atio

n

•Th

e to

ol is

des

igne

d to

sup

port

and

em

pow

er a

ll he

alth

care

pro

fess

iona

ls w

orki

ng in

diff

icul

t ci

rcum

stan

ces

with

lim

ited

reso

urce

s bu

t do

es n

ot s

uper

sede

a d

ecis

ion

by a

n ex

perie

nced

clin

icia

n ab

out

whe

ther

, w

hen

orw

here

to

refe

r an

adu

lt.

•Th

e as

sess

men

t ap

plie

s to

all

adul

ts a

ged

16 y

ears

or

over

and

is in

depe

nden

t of

any

prio

r or

exi

stin

g m

edic

alco

nditi

on.

•Fe

ver

alon

e is

not

use

d as

a c

riter

ion

for

refe

rral

as

it is

a p

oor

disc

rimin

ator

for

sev

ere

illne

ss.

•D

iffic

ulty

in s

elf

care

indi

cate

s a

need

for

ass

essm

ent

but

is n

ot b

y its

elf

a go

od m

easu

re o

f se

vere

illn

ess

orne

ed f

or h

ospi

tal a

dmis

sion

. Re

ferr

al t

o a

com

mun

ity-b

ased

sup

port

fac

ility

may

be

suita

ble.

•W

hen

refe

rral

is n

ot in

dica

ted,

a c

opy

of t

he h

ome

care

advi

ce le

afle

t sh

ould

be

prov

ided

, w

ith e

ncou

rage

men

tto

see

k m

edic

al a

dvic

e ag

ain

shou

ld t

he a

dult’

s co

nditi

on d

eter

iora

te.

•Ev

ery

asse

ssm

ent

shou

ld in

clud

e a

reco

rd o

f th

e tim

e of

ass

essm

ent

and

time

of o

nset

of

illne

ss.

Refe

rral

s m

ust

incl

ude

the

crite

ria la

bel(s

) to

ass

ist

with

the

tre

atm

ent

of a

dults

on

arriv

al a

t ho

spita

l.

The

Swin

e Fl

u A

dult

Com

mun

ity A

sses

smen

t To

ol is

end

orse

d by

: Th

e Ro

yal C

olle

ge o

f G

ener

al P

ract

ition

ers,

Th

e Ro

yal C

olle

ge o

f Ph

ysic

ians

, Th

e Ro

yal C

olle

ge o

f N

ursi

ng,

The

Col

lege

of

Emer

genc

y M

edic

ine,

Th

e D

irect

ors

of C

linic

al C

are

of U

K A

mbu

lanc

e Tr

usts

and

The

Brit

ish

Med

ical

Ass

ocia

tion.

©C

row

n co

pyrig

ht 2

009

Prod

uced

by

CO

I for

the

Dep

artm

ent

of H

ealth

2958

97 1

p Se

p 09

Cri

teri

aR

EFER

AD

ULT

S TO

TH

E N

EAR

EST

GEN

ERA

L H

OSP

ITA

L EM

ERG

ENC

Y D

EPA

RTM

ENT

IF T

HEY

la

bel

PRES

ENT

WIT

H A

NY

OF

THE

FOLL

OW

ING

:

ASe

vere

res

pir

ato

ry d

istr

ess

Seve

rebr

eath

less

ness

, e.

g. u

nabl

e to

com

plet

e se

nten

ces

in o

ne b

reat

h.

Use

of

acce

ssor

y m

uscl

es,

supr

a-cl

avic

ular

rec

essi

on,

trac

heal

tug

or

feel

ing

of s

uffo

catio

n.

BIn

crea

sed

res

pir

ato

ry r

ate

mea

sure

d ov

er a

t le

ast

30 s

econ

ds.

Ove

r 30

bre

aths

per

min

ute.

CO

xyg

en s

atu

rati

on

≤92

% o

n p

uls

e o

xim

etry

, b

reat

hin

g a

ir o

ro

n o

xyg

enA

bsen

ce o

f cy

anos

is is

a p

oor

disc

rimin

ator

for

sev

ere

illne

ss.

DR

esp

irat

ory

exh

aust

ion

New

abn

orm

al b

reat

hing

pat

tern

, e.

g. a

ltern

atin

g fa

st a

nd s

low

rat

e or

long

pau

ses

betw

een

brea

ths.

EEv

iden

ce o

f se

vere

clin

ical

deh

ydra

tio

n o

r cl

inic

al s

ho

ckSy

stol

ic b

lood

pre

ssur

e <

90m

mH

g an

d/or

dia

stol

ic b

lood

pre

ssur

e <

60m

mH

g.St

erna

l cap

illar

y re

fill t

ime

>2

seco

nds,

red

uced

ski

n tu

rgor

.

FA

lter

ed c

on

scio

us

leve

lN

ew c

onfu

sion

, st

rikin

g ag

itatio

n or

sei

zure

s.

GC

ausi

ng

oth

er c

linic

al c

on

cern

to

th

eir

ow

n G

P o

r cl

inic

al t

eam

e.g.

a r

apid

ly p

rogr

essi

ve o

r an

unu

sual

ly p

rolo

nged

illn

ess.

AD

ULT

Date: Time: hrs

Case reference no.: NHS no. if known:

Hospital ref. no.: Ambulance Service job ref.:

Referral to: Ambulance Service target in hosp. time: hrs

Hospital: Own GP:

Name: Date of birth:

Address:

Postcode:

History and examination (circle referral criteria label(s) as appropriate)

REFER PATIENTS TO THE NEAREST GENERAL HOSPITALEMERGENCY DEPARTMENT IF THEY PRESENT WITH ANY OFTHE FOLLOWING:

Circle the referral criteria label(s) below

Children under 16 years old: Paediatric CommunityAssessment tool

Adult Community Assessment Tool

A Severe respiratorydistress

Lower chest wall indrawing,sternal recession, grunting, ornoisy breathing when calm.

Severe breathlessness, e.g.unable to complete sentencesin one breath. Use ofaccessory muscles, supra-clavicular recession, trachealtug or feeling of suffocation.

B Increased respiratory rate

Rate measured over at least30 seconds. ≥50 breaths perminute if under 1 year, or ≥40breaths per minute if ≥1 year.

Rate measured over at least30 seconds. Over 30 breathsper minute.

C Oxygen saturation≤92% on pulseoximetry, breathingair or on oxygen

Absence of cyanosis is a poordiscriminator for severe illness.

Absence of cyanosis is a poordiscriminator for severe illness.

D Respiratoryexhaustion

Apnoeic episode. Apnoeadefined as a ≥20 second pausein breathing.

New abnormal breathingpattern, e.g. alternating fastand slow rate or long pausesbetween breaths.

E Evidence of severe clinicaldehydration orclinical shock

Sternal capillary refill time >2seconds, reduced skin turgor,sunken eyes or fontanelle.

Systolic blood pressure<90mmHg and/or diastolicblood pressure <60mmHg.Sternal capillary refill time >2seconds, reduced skin turgor.

please turn over

COMMUNITY TO HOSPITALREFERRAL FORM

© Crown copyright 2009

Produced by COI for the Department of Health

295897 1p Sep 09

Medications listed/attached

Allergies

Working diagnosis

Other relevant information

Yours sincerely,

(Sign here)

(Any regulated healthcare professional)

Print name of referrer Professional status

NB: New inability to cope at home indicates a need for assessment but may not lead to hospital admission. Admission to a low resource care facility may be moreappropriate.

REFER PATIENTS TO THE NEAREST GENERAL HOSPITALEMERGENCY DEPARTMENT IF THEY PRESENT WITH ANY OFTHE FOLLOWING:

Circle the referral criteria label(s) below

Children under 16 years old: Paediatric CommunityAssessment tool

Adult Community Assessment Tool

F Altered conscious level

Strikingly agitated or irritable,seizures, or floppy infant.

New confusion, strikingagitation or seizures.

G Causing otherclinical concern totheir own GP orclinical team

e.g. a rapidly progressive oran unusually prolongedillness.

e.g. a rapidly progressive oran unusually prolongedillness.

This pathway should be used to manage severe and complicated flu-like illness during severe and exceptionalcircumstances when surge demand for healthcare services leads to a need for strict triage. Practitioners mustremain vigilant for other serious diseases which can present or be referred with symptoms similar to flu-like illness.

Triage assessment tool to be completed in Emergency Department

Swine flu paediatric hospital pathways – Emergency Department management

This template is endorsed by The Royal College of Paediatrics and Child Health, The Royal College ofGeneral Practitioners, The British Paediatric Allergy Immunology and Infection Group, The College ofEmergency Medicine, The British Medical Association, The British Society for Antimicrobial Chemotherapy,The British Infection Society, The Health Protection Agency and The Intensive Care Society.

•••

Flu home care advice, Swine Flu Information numberOseltamivir to complete 5 day course (children <1 year see RCPCH guidance)Co-amoxiclav for 5 days or clarithromycin if allergic to penicillin

Admit (to flu cohortward if available)

(see overleaf)

Severe flu-like illnessbut admission criteria

not met

Criteria CHILDREN UNDER 16 YEARS OLD WILL BE CONSIDERED FOR ADMISSION AT THE NEAREST GENERAL label HOSPITAL IF THEY PRESENT WITH ANY OF THE FOLLOWING:

ASevere respiratory distressLower chest wall indrawing, sternal recession, grunting, or noisy breathing when calm.

BIncreased respiratory rate measured over at least 30 seconds.≥50 breaths per minute if under 1 year, or ≥40 breaths per minute if ≥1 year.

COxygen saturation ≤92% on pulse oximetry, breathing air or on oxygenAbsence of cyanosis is a poor discriminator for severe illness.

DRespiratory exhaustion or apnoeic episodeApnoea defined as a ≥20 second pause in breathing.

EEvidence of severe clinical dehydration or clinical shockSternal capillary refill time >2 seconds, reduced skin turgor, sunken eyes or fontanelle.

FAltered conscious levelStrikingly agitated or irritable, seizures, or floppy infant.

GCausing other clinical concern to the clinical team or specialist doctore.g. a rapidly progressive or an unusually prolonged illness.

please turn over

PAEDIATRIC

This pathway should be used to manage severe and complicated flu-like illness during severe and exceptionalcircumstances when surge demand for healthcare services leads to a need for strict triage. Practitioners mustremain vigilant for other serious diseases which can present or be referred with symptoms similar to flu-like illness.

© Crown copyright 2009

Produced by COI for the Department of Health

295897 1p Sep 09

This template is endorsed by The Royal College of Paediatrics and Child Health, The Royal College ofGeneral Practitioners, The British Paediatric Allergy Immunology and Infection Group, The College ofEmergency Medicine, The British Medical Association, The British Society for Antimicrobial Chemotherapy,The British Infection Society, The Health Protection Agency and The Intensive Care Society.

Diuretics/ACEinhibitors/restrict

fluid balance

Respiratory deteriorationdespite treatment or focal

respiratory signs

Capillary blood gases. Consider non-invasive ventilation.Consider likelihood of benefit of intensive care if available

Return to cohortward or supportive

care

Admit (to flu cohort ward if available)

Oseltamivir may be of some benefit in severe cases ifduration of symptoms <7 days

Continue antibiotics and antipyretics (see overleaf)

Oseltamivir may be of some benefit in severecases if duration of symptoms <7 days

Chest X-ray, FBC, U&E,blood culture, sputum culture,

rapid respiratory pathogen tests asrecommended locally

• Flu home care advice, Swine Flu Information number• Oseltamivir to complete 5 day course

(children <1 year see RCPCH guidance)• Antibiotics to complete 5 day course

Oseltamivir may be of some benefit in severecases if duration of symptoms <7 days

Swine flu paediatric hospital pathways – in-patient management

PAEDIATRIC

This pathway should be used to manage severe and complicated flu-like illness during severe and exceptionalcircumstances when surge demand for healthcare services leads to a need for strict triage. Practitioners mustremain vigilant for other serious diseases which can present or be referred with symptoms similar to flu-like illness.

Triage assessment tool to be completed in Emergency Department

Swine flu adult hospital pathways – Emergency Department management

This template is endorsed by The Royal College of Physicians, The College of EmergencyMedicine, The Intensive Care Society, The British Society for Antimicrobial Chemotherapy,The British Infection Society and The Health Protection Agency.

Admit (to flu cohortward if available)

(see overleaf)

Severe flu-like illnessbut admission criteria

not met

Criteria ADULTS WILL BE CONSIDERED FOR ADMISSION AT THE NEAREST GENERAL HOSPITAL IF THEY label PRESENT WITH ANY OF THE FOLLOWING:

ASevere respiratory distressSevere breathlessness, e.g. unable to complete sentences in one breath. Use of accessory muscles, supra-clavicular recession, tracheal tug or feeling of suffocation.

BIncreased respiratory rate measured over at least 30 seconds.Over 30 breaths per minute.

COxygen saturation ≤92% on pulse oximetry, breathing air or on oxygenAbsence of cyanosis is a poor discriminator for severe illness.

DRespiratory exhaustionNew abnormal breathing pattern, e.g. alternating fast and slow rate or long pauses between breaths.

EEvidence of severe clinical dehydration or clinical shockSystolic blood pressure <90mmHg and/or diastolic blood pressure <60mmHg.Sternal capillary refill time >2 seconds, reduced skin turgor.

FAltered conscious levelNew confusion, striking agitation or seizures.

GCausing other clinical concern to the clinical team or specialist doctore.g. a rapidly progressive or an unusually prolonged illness.

please turn over

ADULT

This pathway should be used to manage severe and complicated flu-like illness during severe and exceptionalcircumstances when surge demand for healthcare services leads to a need for strict triage. Practitioners mustremain vigilant for other serious diseases which can present or be referred with symptoms similar to flu-like illness.

© Crown copyright 2009

Produced by COI for the Department of Health

295897 1p Sep 09

Admit (to flu cohort ward if available)

Continue antibiotics and antipyretics (see overleaf)

Cardiac symptoms –viral myocarditis or heart failure

Neurological symptoms –meningitis or encephalitis

echocardiography

Diuretics/ACEinhibitors/restrict

fluid balance

and focal neurological signs

LP if no contraindicationsSend CSF for microscopy,

culture and sensitivity and virology

Admit and assess progress in ICU

Arterial blood gas. Consider non-invasive ventilation.Consider likelihood of benefit of intensive care if available.

Take specialist advice

criteria met

•••

This template is endorsed by The Royal College of Physicians, The College of EmergencyMedicine, The Intensive Care Society, The British Society for Antimicrobial Chemotherapy,The British Infection Society and The Health Protection Agency.

Respiratory deteriorationdespite treatment or focal

respiratory signs

<7

<7

<7

Chest X-ray, FBC, U&E, blood culture,sputum culture, blood gases,

rapid respiratory pathogen tests asrecommended locally

If pneumonia give IVco-amoxiclav plus

clarithromycin. Alternativesaccording to local policy

Flu home care advice, Swine Flu Information numberOseltamivir to complete 5 day courseAntibiotics to complete 5 day course

Swine flu adult hospital pathways – in-patient management

ADULT

© Crown copyright 2009

Produced by COI for the Department of Health

295897 1p Sep 09