January 2019

In this issue:

Building resiliency in a high-stakes environment

A message from Thomas Balcezak, MD, Chief Medical Officer

As much as I love the Northeast’s seasons, Connecticut in the cold and bleak days at the beginning of the year tests my optimism. For many of us on the medical staff, this January was made more difficult by the news of the untimely passing of Drs. Frank Lobo and Deepak Narayan. As I mentioned in an email I sent a few weeks ago, both made huge contributions to the health of our patients, the quality of care provided at this hospital, the human fabric of this hospital & medical staff, and the communities in which they lived. We are privileged to have known them.

The weight of those losses reinforced how important it is for us physicians to be resilient in the face of inevitable personal and professional challenges. While everyone experiences loss, insecurity, and setbacks, the working environment of physicians brings the additional weight of responsibility for our patients’ health, expectations of high performance in a high stakes environment, a sense of responsibility for the success of our practices or teams, and other challenges. Despite those high expectations, our professional culture is not one that welcomes acknowledging or seeking help for issues of guilt, doubt, despair, or challenging personal circumstance.

I wrote last month about our imperative to attack the systemic and structural drivers of physician burnout. It is also essential to discuss how we can improve the professional culture of medicine by building structures that create an appreciation for personal wellness. Our medical staff engagement surveys have confirmed this need. Additionally, as I have written previously, we noted that despite their centrality to front line patient care, our residents and fellows often feel disconnected from the greater hospital community.

Over the past two years, as a way to create a roadmap to support a culture of engagement wellness among the Medical Staff at large, our Office of Graduate Medical Education has developed a robust Resident/Fellow Senate with programming that targets key areas, including well-being and resilience.

After stepping down as Designated Institutional Officer and Associate Dean for GME in 2016, Dr. Rosemarie Fisher partnered with her successor, Dr. Stephen Huot, to take on the newly created role of GME Director of Wellness. In collaboration with our training program directors and leaders of the GME Senate Wellness Council, we have now implemented programs that I could not have dreamed of when I trained here nearly three decades ago.

The multifaceted programming we have implemented runs the gamut from social activities to targeted support resources. We now support monthly cross-program social activities and biannual “Evenings of Solidarity” that foster collaboration, esprit de corps and a greater sense institutional connectedness. We have remodeled the resident lounge, and support a capstone resident/fellow Appreciation Week which we are celebrating this week and includes a wide range of activities. We have organized professional and peer support for our trainees by sharing best practices in wellness curricula across training programs, creating a Peer Support program where trainees from across specialties receive professional training in counseling and crisis intervention, and setting up introductory appointments with local therapists on an opt-out basis to discuss adjustment to the new responsibilities of training and to be an available resource to any trainee who wishes to continue sessions. These resources can also facilitate referrals to additional confidential behavioral health and substance abuse professionals when needed. We have also significantly increased support of our Minority Housestaff Organization and this winter supported the formation of the Yale-New Haven Women’s’ Housestaff Organization. These entities provide additional programming that engages our residents and fellows, provides mentorship, and helps support our institutional goals of promoting diversity and inclusion.

These programs will continue to grow. My office will seek to learn from the successes with our trainees, and scale them to tailor support resources for the rest of our Medical Staff. The well-being of our medical staff is not a luxury or perk - it is foundational to the provision of exceptional, patient centered and high value care, and to our aspirations to maintain and build on our position as one of the nation’s premiere healthcare institutions. I thank you for your ongoing engagement, and welcome your questions and comments. As ever, I can be reached via e-mail at thomas.balcezak@ynhh.org.

 

Patient Safety and Quality Metrics

12-Month Period

12/16-11/17

1/17-12/17

2/17-1/18

3/17-2/18

4/17-3/18

5/17-4/18

6/17-5/18

 7/17-6/18  8/17-7/18  9/17-8/18 10/17-9/18
 11/17-10/18

C. diff

162

164

167

167

159

169

174

 171  173  176  179  177

CAUTI

84

84

80

77

73

73

66

 59  55  56  59  54

CLABSI

82

82

79

80

78

75

76

 79  73  72  75  74

SSE

25

22

19

18

17

16

18

 16  15  12  11  13

 

         

12-Month Period

10/16-9/17

11/16-10/17

12/16-11/17

1/17-12/17

2/17-1/18

3/17-2/18

4/17-3/18

 5/17-4/18  6/17-5/18  7/17-6/18  8/17-7/18 9/17-8/18

Colon SSI

52

49

47

46

44

46

41

 41  43  45  44  50

Hysterectomy SSI

6

5

7

8

10

9

12

 12  13  14  16  17

PE/DVT

85

81

78

67

71

70

68

 70  66  69  67  63

Iatrogenic Pneumothorax

10

11

8

6

7

6

6

 5  6  7  6  6

The Patient Safety and Quality metrics are reported on a 12-month rolling timeframe. The most recent timeframes differ based upon the various databases reporting the metrics. 12-month rolling total updated with AHRQ v6.0 definition starting January 2017.

Patient Safety and Quality Metric Definitions

Colon and Hysterectomy SSI: A surgical site infection within 30 days of the operative procedure, classified as superficial, deep, or organ/space infections based on CDC/NHSN surveillance definitions.

C. diff (Clostridium difficile): A patient who develops diarrhea greater than 48 hours after admission to an inpatient unit and for whom the C. diff testing (either rapid toxin, cytotoxin or PCR) is positive.

CAUTI (Catheter Associated Urinary Tract Infection): A patient who has an indwelling urinary catheter in place for over two days, with at least one of the following signs or symptoms: fever > 38○ C, suprapubic tenderness (with no other recognized cause), costovertebral angle pain/tenderness (with no other recognized cause), urinary urgency (not while catheter in place), urinary frequency (not while catheter in place), or dysuria (not while catheter in place).

CLABSI (Central Line Associated Blood Stream Infection): A primary bloodstream infection (not related to an infection at another site) that develops in a patient with a central line in place over two days before onset of the infection. Culturing the catheter tip is not a criterion for a CLABSI.

Iatrogenic Pneumothorax: A pneumothorax caused by medical care, with certain exclusions for trauma, cardiac and thoracic surgery patients.

PE/DVT (Pulmonary Embolism/Deep Vein Thrombosis): Any PE/DVT that occurs postoperatively.

Serious Safety Event: A deviation from generally expected care that results in moderate to severe patient harm.

 

 

U.S. News & World Report opens in February

U.S. News & World Report, working with Doximity, opened voting for the news magazine’s annual “Best Hospitals” issue. All board-certified physicians within each of the applicable specialties surveyed (i.e., Cancer, Cardiology/CT Surgery, Diabetes/Endocrinology, ENT, Gastroenterology/GI Surgery, Geriatrics, Gynecology, Nephrology, Neurology/Neurosurgery, Ophthalmology, Orthopedics, Psychiatry, Pulmonary, Rehabilitation, Rheumatology and Urology) should receive a request to vote in the U.S. News reputation ranking either via email or as a prompt when logging in to Doximity.

This is your opportunity to make your voice heard about the exceptional care that is provided across Yale New Haven Health. All System hospitals and ambulatory practices are home to exceptional physicians who continually advance medicine through the safe, high quality and compassionate care provided to our patients. We believe that the reputation of the entire health system would be greatly enhanced if Yale New Haven Hospital is voted into the Honor Roll. One barrier to this historically has been the reputational score which is determined by your vote. We would urge you to consider this as you cast your vote during the voting period. Thank you for your participation.

 

CVS Pharmacy: ICD-10 code requirement for opiate prescriptions

CVS Pharmacy now requires an ICD-10 on all opiate prescriptions. On several occasions, controlled substance prescriptions for opiates that were prescribed to local CVS pharmacies were delayed or not processed due to lacking an accompanying ICD-10 code.

In an effort to combat the opiate crisis, CVS Pharmacy now requires that all prescriptions for opiates (regardless of schedule) have an accompanying ICD-10 code. This is conducted as a quality assurance check to ensure that pharmacists properly exercise their professional responsibility to evaluate controlled substance prescriptions prior to filling them.

The tips, below, will assist you in adding the ICD-10 code to your opiate prescriptions. This will prevent unnecessary phone calls and patient delays in filling their opioid prescription at local CVS pharmacies:

Diagnosis Association from Discharge Medication Reconciliation

  • Enter the prescriptions you want to order during the Discharge Med Rec Process.
  • Under the Manage Orders sidebar within the Discharge Med Rec section of the Discharge Navigator, you will view a list of actions that will take place upon signature.
  • Click DX Association to open the Associate Diagnosis window.
  • In the Associate Diagnosis window, click the checkbox for the diagnosis you wish to associate each drug with.
  • Only problems from the patient’s problem list will appear on top. To add a separate diagnosis, use the Add Diagnosis field to search and enter that diagnosis.

Diagnosis Association from Orders Only/Ambulatory Encounters

  • From within the Add Order section of the encounter you still need to associate controlled medications with a diagnosis.
  • After entering new controlled prescriptions in the encounter, click on DX Association
  • This will open up the same Associate Diagnosis window from earlier.
  • Check off the diagnosis for association. If a diagnosis is not listed, use the Diagnosis field to search for and add a diagnosis to associate with.
  • Click Accept to associate the diagnosis to the drugs selected.

Diagnosis Association from Emergency Department Dispo Activity

  • From within the Dispo activity discharge meds section you will need to associate controlled medications with a diagnosis.
  • After entering new controlled prescriptions in the encounter, click on the options divot and choose DX Association.
  • This will open up the same Associate Diagnosis window.
  • Check off the diagnosis for association. If a diagnosis is not listed, use the Diagnosis field to search for and add a diagnosis to associate with.
  • Click Accept to associate the diagnosis to the drugs selected.

 

YNHHS makes disclosure CLEAR among physicians, staff and patients

By Alan Friedman, MD

Yale New Haven Health System’s culture supports the timely and detailed reporting of patient safety events, which is consistent with our commitment to drive the incidence of medical errors to zero. While we have adopted the approach to speak openly with each other about medical error thereby fostering shared learning across the organization, we have also committed to having open, honest and transparent discussion with the patients and their families who have experienced a medical error. We refer to this process as “disclosure,” and it is informed by our standards of professional behavior especially those of compassion, integrity and accountability.

Disclosure always begins with a sincere apology. It is followed by an investigation by our safety team that helps us understand exactly what the error was, how it happened and what actions we are taking to ensure that the error will not recur to another patient. We convey all of this information to the patient and family when we have a clear understanding of the specifics and we then make the commitment to them that we will continue to update them on what we learn and what we do to further patient safety. This process aims to build trust and a strong bond between our physicians, YNHHS staff and our patients.

The disclosure process at YNHH and across the health system is referred to as CLEAR, which stands for Communication Leads to EArly Resolution. We expect to have disclosure with every serious safety event in our health system and while these conversations are difficult for all, they are essential to our sense of professional integrity.

We have a team of coaches that are available to help clinicians prepare for the conversations, to guide and advise them on the best language and approach and provide feedback to the patient and families after the disclosure. Importantly, we are building a responsive peer support program for all of our clinical staff. We know staff involved in a clinically unexpected outcome may suffer emotional distress following the event. It is important we provide care and support for each other, which allows us to better care for our patients.

For more information, please contact Alan Friedman, MD, at alan.friedman@yale.edu.

 

Protect patients’ privacy as if it were your own

Your spouse just had a test at a YNHHS facility, and you’re really anxious to get the results. Is it OK for you to go into Epic and access your spouse’s medical record?

The answer is no. Doing so would violate HIPAA and Yale New Haven Health policies, and you could be subject to disciplinary action. Illegally accessing protected health information also puts the hospital and health system at risk of federal penalties, which can include fines.

“Our family members, friends and co-workers are entitled to the same privacy as any other patient,” said Terrie Estes, vice president, Corporate Compliance, and chief compliance officer, YNHHS. “Many employees have been patients at one time or another, and we would want the same protection for our privacy.”

YNHHS has seen an increase in reports of people inappropriately accessing medical records. Part of the reason for the increase is better monitoring by Information Technology Services’ Office of Information Security. Another reason is that employees are more frequently reporting inappropriate access and other violations, said Glynn Stanton, vice president and chief information security officer, ITS.

“Just as reporting of near-miss safety events is helping to improve patient safety, monitoring and reporting privacy concerns will help us better protect sensitive information,” he said.

In the coming months, Compliance and ITS will provide reminders and tips about how you can help keep sensitive information secure. Watch for these communications in the newsletters and on the employee intranet.

“We’re here to protect our patients, our staff and our organization,” Estes said. “But we can’t do it alone. We need everyone’s help.”

 

Newly appointed medical staff members: How to register for HRO training

Yale New Haven Health System is a High Reliability Organization (HRO). All newly appointed medical staff members are required to attend an HRO training session within 90 days of initial appointment. You do not need to wait until you are appointed to attend HRO training. You can do so while your application is being processed. Note that if you have already attended HRO training at any YNHHS hospital you have fulfilled this requirement. Please inform your credentialing specialist.

To register for an HRO training session, follow these steps:

Visit ynhh.org and select “Services” at the top of the page.

  • Select “Classes and Events.”
  • Type “HRO Training” in the search box and click the box(es) below the calendar for the entity you are joining (or any locations you would consider for training). Press “Go.” (Note: You can also narrow the search by changing the month on the calendar.)
  • Scroll down on the left and choose the date, time and location that is most convenient for you. Click “Details and registration” and then “Register Now.” If you experience any difficulty or have any questions, please email Kathleen Quinn or call 203-688-5242.

 

Communications workshop available for clinical staff

Physicians, advanced practice providers (APPs) and nurses across Yale New Haven Health and Yale Medicine are urged to sign up for “Enhancing Relationship-Centered Communication,” a course offered through YNHHS Patient Experience.

This one-day, peer-led workshop will show how communication can improve health outcomes, patient satisfaction and professional engagement. The session includes didactic presentations, live demonstrations and practice activities with guided feedback to enhance relationship-centered communication skills. The goal of this course is to improve interactions between healthcare professionals and patients as well as conversations with colleagues and staff. The workshop also teaches clinicians to be more mindful in their approach with patients and families.

Sessions are available through April 2019. Upon completion, participants will receive 7 AMA PRA Category 1 credits. Register at www.ynhh.org/events. Search for “communication” for a listing of upcoming dates. Sessions are 8 am - 4 pm at the YNHHS SYN:APSE Center for Learning, Transformation and Innovation, 730 Howard Ave., New Haven.

 

Newsmakers

Victor Morris, MD, has accepted the role of the interim chief medical officer for Milford Hospital. As of January 1, 2019, Dr. Morris became responsible to the Milford Board of Trustees and Mark Toney, president and chief executive officer for Milford Hospital. Dr. Morris assumed responsibility for medical staff oversight, physician relations, clinical care oversight, and direction of the quality, safety, accreditation and regulatory programs for Milford.

This is an important role for Milford Hospital, as YNHHS moves to complete the acquisition during 2019 and Dr. Morris is uniquely qualified to assist Milford Hospital’s leadership in this endeavor. We are pleased that Victor has accepted this short-term assignment, and we fully expect that he will return to his previous role upon completion of the transaction.

It is important to note that in the interim between Jan. 1 and completion of the transaction, while Dr. Morris is working for Milford Hospital, YNHH must completely reassign all of his current responsibilities, direct reports and administrative functions within Yale New Haven Hospital and Yale New Haven Health. Also during this period, it is important to note that Dr. Morris will have no access to any Yale New Haven confidential information and he will be treated as a Milford Hospital full-time employee. Dr. Morris will remain on Yale New Haven Hospital medical staff and continue to provide clinical care to his patients during this time.

Ernest D. Moritz, MD, FACP, will be named a Master of the American College of Physicians (ACP) during the annual ACP meeting in Philadelphia, April 11-13, 2019. Only a select few physicians gain the designation of “Master,” a position of stature for which one does not apply; it is bestowed upon the deserving. ACP bylaws state that Masters shall be Fellows who have been selected because of “integrity, positions of honor, eminence in practice or in medical research, or other attainments in science or in the art of medicine. Masters must be highly accomplished persons demonstrating eminence in practice, leadership, or in medical research.”

Joan Kelly has been named chief experience officer, Yale New Haven Health System. She joined YNHHS from NYU Langone Health in New York, where she was chief patient experience officer for four years. Before joining NYU Langone, Kelly founded ROAR Health, which provided consulting services on transforming the healthcare experience and health outcomes. Before that, she was corporate director for Consumer Experience, Innovation and Well-Being at Humana in Louisville, KY. Kelly earned her MBA from Simmons College, Boston, and is pursuing her doctorate from the University of Pennsylvania.

 

In Memoriam

Francis M. Lobo, MD, 54, of New Haven, died Dec. 22 at his home. He was known to be extremely generous with his time, talent and funds to help his neighborhoods of City Point and the Hill in New Haven. A graduate of the University of Pennsylvania, Dr. Lobo received a master's in philosophy and history from Cambridge University. Dr. Lobo was a graduate of Yale School of Medicine, and did his residency at Yale New Haven Hospital. He was a Fulbright scholar at Ludwig-Maximilians University in Munich, Germany. He also was past president of the Beaumont Medical Club of Connecticut, and a member of New Haven Farms Board of Directors. He was a trustee of the Harvey Cushing/John Hay Whitney Medical Library, and a member of the executive committee of the Association of Yale Alumni in Medicine.

John A. Merritt, Jr., MD, 87, of Mount Pleasant, South Carolina (formally of Guilford, Connecticut), died Nov. 17, 2018. After receiving an undergraduate degree from Dartmouth College, he earned his medical degree from Yale University School of Medicine. He received American Board Certifications in Geriatric Medicine, Hematology and Internal Medicine, as well as a fellowship in the American College of Physicians. He was appointed to assistant professor of Medicine at Yale University, University of Massachusetts and Tufts University Schools of Medicine. John served as a captain in the Air Force School of Aerospace Medicine in San Antonio, Texas.

He was chief of Medicine at Worcester City Hospital in Worcester, Massachusetts, and at the Hospital of Saint Raphael in New Haven. As the Hospital of Saint Raphael's first chief of Geriatric Medicine, Dr. Merritt created programs such as Project Eldercare, which became embedded in the community.

Deepak Narayan, MBBS, FRCS, passed away Dec. 24 after a brave battle with cancer. During his storied and highly successful career at Yale Cancer Center and Smilow Cancer Hospital, Dr. Narayan was a professor of Surgery, clinical program leader of the melanoma program, and chief of Plastic Surgery at the West Haven VA Hospital.

An internationally renowned surgeon, Dr. Narayan was a gifted clinician, an accomplished scientist and a valued friend and colleague to the YCC/SCH community. During his tenure as clinical program leader, the Melanoma Program was recognized as a pre-eminent center of excellence that continuously launched medical and surgical innovations to improve outcomes for our patients. At the same time, Dr. Narayan was committed to enhancing the patient and family experience, and, in that vein, he co-authored Win the Fight, Stomp out Melanoma, a guide for patients and families.

 

New Yale Addiction Medicine Consult Service at YNHH’s Saint Raphael Campus

The Yale Addiction Medicine Consult Service (YAMCS) is available at Yale New Haven Hospital’s Saint Raphael Campus (SRC). YAMCS treats patients either when they are admitted to the hospital for a medical condition related to the substance use or when they are found to have a substance use disorder during their evaluation, according to Melissa Weimer, DO, medical director, YAMCS.

If you have a patient who needs a consult, complete the referral in Epic. Currently, the service is only available at the SRC campus. Patients with infective endocarditis, however, may also be seen at the York Street Campus.

 

Request for patient stories

Yale New Haven Health often features patient stories to highlight the work and dedication of our physicians, nurses and staff in its print publications, websites and advertising campaigns. If you have a patient that you think would make a great story -- and who is willing to share his or her experience -- please contact Cynthia Whitcomb at 203-688-9440.

 

Influenza Guidance

January 2019

Each year, influenza has great impact on our patients. This brief overview provides guidance for the diagnosis, treatment and isolation of persons suspected of having influenza.

Of course, vaccination is the best way to prevent the flu and it is recommended for all persons 6 months and older by the CDC with few exceptions. It is recommended that those still not vaccinated get vaccinated as soon as possible.

For further details, please visit the CDC flu vaccination website at: http://www.cdc.gov/flu/protect/vaccine/index.htm.

Influenza Diagnosis

An influenza-like illness (ILI) should be suspected in a person with a fever or who is feeling feverish/chilled and has:

  • Respiratory tract signs such as a cough, sore throat or rhinorrhea,
  • Headache, and
  • Systemic symptoms such as fatigue or myalgias

The onset of these signs and symptoms is typically acute where the patient goes from feeling well to recognizing they are sick within a few hours. Vomiting or diarrhea is often present in children infected by influenza, but these signs are less common in adults. Norovirus should be considered for patients where nausea, vomiting and diarrhea are the predominant symptoms/signs.

Influenza often does not present as a classic ILI. Influenza virus can cause uncomplicated upper respiratory tract infections and the severity of disease can also be lessened by prior vaccination. In the elderly, the presentation of influenza can be very non-specific. In some, the new onset or worsening malaise may be the primary finding while fever and cough are less prominent. In infants and other young children, fever may be the only presenting sign or symptom.

Who should be tested for influenza?

Testing for influenza should be performed for patients when the results lead to an immediate or possible future action. For example, for patients sick enough to be hospitalized, testing for influenza will both guide antiviral treatment and determine their Infection Prevention isolation needs (see below). For those who do not require hospitalization, testing should be considered for patients who may develop complications from the flu or whose illness may progress and lead to hospitalization. Finally, if there is uncertainty for the cause of a patient’s acute illness, testing for influenza may help to confirm (or refute) flu and may help establish the presence of influenza in the patient’s community.

Clinicians should not wait for test results before taking action on the following:

  • Antiviral medications, if indicated, should always be started as soon as possible. For outpatients, antiviral treatment does not require testing for influenza.
  • Emergency Department and Urgent Visit Disposition: Rapid influenza PCR results should be available within 1-1.5 hours and assist acute management decisions. Other respiratory virus results can be communicated with the patient when they become available- patient disposition should not be delayed due to waiting for non-rapid respiratory virus test results.
  • Bed Management and Infection Prevention: Patients with rapid influenza PCR testing should await results to assist in bed placement. If negative for influenza, hospitalized patients with acute respiratory tract infections are empirically placed in both Droplet and Contact Precautions. The sample for Respiratory Virus PCR Panel testing should be sent to the lab as quickly as possible and patient isolation can be modified based on the results. (This test may also be run on the existing specimen in the lab for patients who had a Rapid Influenza PCR test.)

What test should I order at YNHH?

  • For ED/Urgent Visit patients likely to be hospitalized order “Influenza A/B by PCR [LAB9374]”. This test provides results within ~1 hr of arrival in the laboratory and is available 24/7 at all YNHH ED sites (YSC, SRC, SMC). Results will be returned prior to admission and will impact bed assignment.
  • If the rapid Influenza A/B by PCR is negative and a patient with symptoms concerning for a respiratory virus infection is hospitalized, order the full Respiratory Virus PCR Panel [LAB3444] to the sample in the laboratory to detect other viral pathogens and to assist in Infection Prevention.

  • For outpatients who are immunocompromised, or at high risk for complications for whom treatment decisions will depend on test results, “Influenza A/B by PCR [LAB9374].” is recommended. If a more comprehensive viral diagnosis will affect outpatient management, order the full “Respiratory Virus PCR Panel [LAB3444]”. Results for the full panel are generally available within 10-24 hours.
  • For other outpatients, the less expensive though less sensitive Respiratory Virus DFA is often the best value. This test detects 7 viruses (Influenza A, B, RSV, parainfluenza 1-3, and adenovirus) and performs best in young children.
  • For Obstetrics inpatients in Labor and Birth or a postpartum unit, when a positive flu test result will lead to separation of mother from newborn, order “Flu/RSV RT-PCR (Labor and Delivery) [LAB8936]”. This is currently the only rapid PCR option available for inpatients. At the York Street Campus, call the Virology laboratory at 203-688-3524 to expedite testing; after hours, call the Microbiology Laboratory at 688-2649. At the Saint Raphael Campus, call the Core Laboratory at 203-789-3060.

 

Influenza Treatment

Neuraminidase inhibitors are the primary class of antiviral medications used to treat influenza and there are 3 neuraminidase preparations available; 1) Oseltamivir (Tamiflu®)- a PO capsule which may be reconstituted as a PO liquid, 2) Zanamivir (Relenza®)- an inhaled dry powder, and 3) intravenous Peramivir (Rapivab®) [non-formulary]. Resistance to each of these antiviral medications has been described and is tracked by the CDC.

Early use of neuraminidase inhibitors has been shown to modestly decrease the duration of illness, prevent hospitalizations, and prevent complications of influenza, including death. If antiviral medication is prescribed, it should be initiated as soon as possible. Clinical benefit of treatment is greatest when these medications are started early.

Clinicians should not wait for influenza test results prior to starting antiviral treatment. For patients with severe, progressive disease, it is recommended that antiviral treatment be initiated regardless of the timing relative to the onset of illness.

Neuraminidase inhibitor (NA) adverse effects: NA are typically well tolerated but occasionally may have some mild to moderate effects that can be difficult to differentiate from patients’ underlying illness. Mild to moderate nausea, vomiting, gastric upset and diarrhea has been noted. These adverse effects are more common in children than adults. Rare instances of abnormal behavior have been associated with use of oseltamivir, but the association remains uncertain

New for 2019!

Baloxavir Marboxil (Xofluza™) is an antiviral medication with activity against the influenza virus. Baloxavir is an endonuclease inhibitor - working by a different mechanism of action than the neuraminidase inhibitors. Baloxavir is only available in an oral formulation and it is prescribed as a one-time, single dose. Baloxavir was recently approved by the FDA for the treatment of influenza in patients 12-years of age and older who also weigh greater than 40 kgs. As with the neuraminidase inhibitors, antiviral treatment for influenza should be started as soon as possible for optimal benefit.

Baloxavir was added to the YNHHS inpatient pharmacy formulary for patients being admitted to this hospital for influenza treatment.

Who should be treated?

Clinicians should consider treatment for patients 1) with severe disease (e.g., those hospitalized for flu), 2) who are at high risk for complications due to flu (see below), 3) who live with a person at high risk for complications due to flu, or 4) any otherwise healthy patient (if within 48 hours illness). Per the CDC/Advisory Committee on Immunization Practices, patients at high risk for complications due to influenza for whom treatment should be prescribed include:

  • Persons who require hospitalization for influenza (even if beyond 48 hours since onset of illness);
  • Women who are pregnant or within 2 weeks post-partum;
  • Persons who are obese (BMI > 40);
  • Persons at the “extremes” of age: > 65 years-old; < 5 years-old (especially those < 2 years-old);
  • Persons with chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematologic (including sickle cell disease), metabolic disorders (including diabetes mellitus) or neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorders), stroke, intellectual disability (mental retardation), moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);
  • Persons with immunosuppression, including that caused by medications or by HIV infection;
  • Persons aged ≤18 years who are receiving long-term aspirin therapy;
  • American Indians/Alaska Natives; and
  • Residents of nursing homes and other chronic-care facilities.

For additional information, see: https://www.cdc.gov/flu/antivirals/index.htm

Isolation Precautions for Patients with Suspected Influenza Infection

All areas: Universal Respiratory Etiquette

  • Perform hand hygiene with Purell (alcohol-based hand rub) or soap and water.
  • Patients and visitors to outpatient areas, including the ED and urgent care areas, are required to wear surgical masks to cover their nose and mouth. Persons unable to wear a mask should be provided with facial tissues to allow them to cover their nose/mouth when coughing/sneezing.
  • Masks and tissues can be made available at busy entrances.
  • Signs are available through the Print Center on Marketplace (http://marketplace.ynhhs.org/); F numbers 7593, 7594 & 7595.

Hospital: Droplet Precautions

  • Droplet precautions are required for patients known or suspected of influenza infection. These patients should be placed in a private room. If a private room is unavailable, the curtain around the ill patient should remain closed.
  • Droplet Precautions must be ordered in Epic by the physician/LIP & Nursing will place a Droplet Precautions sign on the patient’s door.
  • In addition to following Standard Precautions, all staff must wear a standard surgical face mask when within 6 feet of the patient. However, for practical purposes, visitors and staff should put on the mask upon entry to the room.
  • Nursing should discuss these precautions with family members and visitors and ask that they 1) limit the number of persons visiting, 2) carefully wash their hands before, during and after their visit, and 3) wear a standard surgical mask when within 6 feet of the patient/room entry.
  • During patient transport, the patient is to were a standard surgical mask and transport should be coordinated to minimize time spent waiting for elevators, rooms to open, etc.

Other Flu Prevention Tips

  • Get vaccinated and be sure to check that all patients have been vaccinated this season
  • Wash hands frequently and always wash hands after coughing or sneezing
  • Cover your cough- preferably with a tissue, but if one is not available, cough or sneeze into your sleeve rather than your hands
  • Keep surfaces clean using the purple top disinfectant wipes found throughout the hospital
  • Stay home if you’re sick

Questions about this guidance should be referred to YNHH Hospital Epidemiology and Infection Control at 203-668-4634 (203-444-6579 after hours) or Dr. Richard Martinello, Medical Director, Infection Prevention, at richard.martinello@yale.edu.

References