Long-Term Care Survey Alert

Take notes from those who know firsthand what will-and won't-work.

Translate hindsight into foresight to keep the flu bug at bay this year--or stop it in its tracks at the first signs and symptoms of an acute febrile respiratory illness.

Two Maryland nursing homes--Stella Maris and Levindale Hebrew Geriatric Center & Hospital--have several key lessons to share from their battle with Type A influenza last winter.

1. Vaccinate staff before flu hits. Stella Maris had a 34 percent flu vaccination rate for staff early in its flu outbreak last winter, said Bernie Miller, RN, BSN, an infection control practitioner at the Timonium, MD facility, who presented during a recent Centers for Medicare & Medicaid Services-sponsored Webcast on flu and pneumonia immunizations. When Stella Maris tracked staff who called in with flu-like illness, they found that those who said they had received flu immunizations didn't miss work for more than two days.

Staff education tip: Educate staff that the flu immunization   doesn't produce antibody protection for a couple of weeks after vaccination. "When the outbreak began, we were bombarded in the medical services by people asking for the flu shot--they thought the vaccine worked over night," said Miller.

Levindale offered both the flu shot (inactivated virus) as well as  FluMist (live nasally administeredvirus) to needle-phobic staff. "FluMist is all we had initially, due to the vaccine shortage last year," reported Stephanie Mayoryk, RN, BSN, CIC, infection control practitioner for the Baltimore facility. (The Food & Drug Administration has approved FluMist for non-pregnant healthy people ages five to 49.)

Tip: Staff who receive FluMist should not care for severely immun- ocompromised residents (such as a bone-marrow recipient) after immunization, said Ray Strikas, MD, with the Centers for Disease Control & Prevention. (The FluMist package inserts says individuals receiving the vaccine should avoid close contact with immunocompromised individuals for 21 days.) Defining who is severely immunocompromised in the nursing home setting can be a judgment call, noted Strikas. But Mayoryk noted that Levindale administered over 100 doses of FluMist to staff during the vaccine shortage last year without any issues. (For more information on FluMist, go to www.fda.gov/cber/label/inflmed061703LB.pdf.)

2. Try to immunize every resident who is eligible to receive the vaccine. After the first round of immunizations, make a list of residents or their responsible parties who declined the immunization so  physicians or nurse practitioners can counsel those folks one-on-one, advised Levindale medical director Susan Levy, MD. That strategy proved successful in getting even the hold outs to accept immunization.

3. Implement flu containment efforts based on flu-like symptoms rather than waiting for laboratory confirmation. In retrospect, Stella Maris could have possibly gained a two-day lead on the flu outbreak if it had taken that tack, according to the Webcast, as initial cultures from symptomatic residents were negative for influenza.

4. Contact the health department to report an outbreak and tap their expertise. The health department can "get things done in the facility because it represents an authority figure," noted Gary Thompson with the Baltimore Department of Health. "We also have experience managing 50 to 60 outbreaks a season and know what works--and what other facilities have done in that regard."

5. Revisit infection control basics. Physicians and the infection control coordinator and educators in the facilities went unit to unit to emphasize proper handwashing and  give out extra supplies of alcohol-based hand sanitizer. They discussed how to help residents with handwashing and talked to staff about using personal protective equipment.

6. Halt group activities and restrict admissions. Levindale stopped admitting patients to the affected units until the flu outbreak was over. The facility also stopped all group activities and closed the dining hall. The dietary department brought meals on trays to residents in their rooms. Staff also called families and visitors of affected units and notified them the facility was seeing a cluster of upper respiratory infections. "We asked the families to stay home--especially if they weren't feeling well themselves," said Mayoryk.

Stella Maris asked the admissions staff to stop giving people tours of the building during the flu outbreak, "which was a first for them," Miller noted.

Give visitors a heads up: Some facilities put up tastefully done notices in the lobby asking visitors to refrain from coming in if they have specified symptoms, and offering to contact the person's resident to let them know the person came to visit, etc., says Judy Gross, RN,C, CDONA/LTC, RAC-C, a consultant with LBK Health Care Inc. in Dayton, OH.

7. Use antiviral prophylaxis, Rx appropriately. Use of antiviral agents is a key element in outbreak control, said Strikas. Antiviral agents include amantadine and rimantadine for influenza A and oseltamivir for either influenza A or B.

Follow these directions: Use antivirals for asymptomatic residents  for two weeks or at least one week after the last documented case of acute febrile respiratory illness, Strikas advised. "Also give symptomatic residents antiviral agents for five days as treatment," he added. Separate residents with flu symptoms receiving antiviral agents from others in the facility to limit transmission of antiviral-resistant influenza, Strikas stressed.

Staff should consider taking antiviral agents if they haven't been vaccinated against the flu--or were vaccinated less than two weeks before exposure, advised Strikas.

Tip: Monitor residents receiving antiviral agents for CNS disturbances, including confusion and dizziness, particularly residents receiving amantadine, said Strikas.

8. Find ways to keep everyone on the same page. For example, Miller sent an e-mail each morning and evening to all the managers to debrief them about the affected units, new cases--and any health department directives. Call department meetings to let all department heads know what interventions you're using and what to tell their employees, advised Levy.

You can consider the flu outbreak to be over when you have no new cases for a week, Strikas advised. But continue monitoring weekly because you can have more than one outbreak in the flu season.

Editor's note: View the CMS Webcast at www.cms.internetstreaming.com.