swine flu clinical package for use when there are exceptional … · 2017. 6. 29. · swine flu...
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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
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. I
t w
ill a
ssist
with
dec
idin
g w
heth
er a
sic
k fe
brile
chi
ld w
ith f
lu-li
ke il
lnes
s ne
eds
refe
rral
to t
he n
eare
st g
ener
al h
ospi
tal E
mer
genc
y D
epar
tmen
t. M
ost
child
ren
are
expe
cted
to
be m
anag
ed in
the
com
mun
ity.
Res
pir
ato
ry f
ailu
re,
ove
rwh
elm
ing
gas
tro
ente
riti
s, s
ho
ck,
hea
rt f
ailu
re a
nd
en
cep
hal
itis
are
th
e m
ost
lik
ely
mo
des
of
crit
ical
illn
ess
in c
hild
ren
su
ffer
ing
fro
m s
win
e fl
u.C
ompl
icat
ions
suc
h as
sep
sis
and
men
ingi
tism
ay c
o-ex
ist.
Cri
teri
aR
EFER
CH
ILD
REN
TO
TH
E N
EAR
EST
GEN
ERA
L H
OSP
ITA
L EM
ERG
ENC
Y D
EPA
RTM
ENT
IF
lab
elTH
EY P
RES
ENT
WIT
H A
NY
OF
THE
FOLL
OW
ING
:
ASe
vere
res
pir
ato
ry d
istr
ess
Low
er c
hest
wal
l ind
raw
ing,
ste
rnal
rec
essi
on,
grun
ting,
or
nois
y br
eath
ing
whe
n ca
lm.
BIn
crea
sed
res
pir
ato
ry r
ate
mea
sure
d ov
er a
t le
ast
30 s
econ
ds.
≥50
brea
ths
per
min
ute
if un
der
1 ye
ar,
or ≥
40 b
reat
hs p
er m
inut
e if
≥1ye
ar.
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
or
apn
oei
c ep
iso
de
Apn
oea
defin
ed a
s a
≥20
seco
nd p
ause
in b
reat
hing
.
EEv
iden
ce o
f se
vere
clin
ical
deh
ydra
tio
n o
r cl
inic
al s
ho
ckSt
erna
l cap
illar
y re
fill t
ime
>2
seco
nds,
red
uced
ski
n tu
rgor
, su
nken
eye
s or
fon
tane
lle.
FA
lter
ed c
on
scio
us
leve
lSt
rikin
gly
agita
ted
or ir
ritab
le,
seiz
ures
, or
flo
ppy
infa
nt.
GC
ausi
ng
oth
er c
linic
al c
on
cern
toth
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.
Swin
e fl
u p
aed
iatr
ic c
om
mu
nit
y as
sess
men
t to
ol
For
use
in
all
child
ren
un
der
16
year
s o
ld i
n t
he
com
mu
nit
y.
Furt
her
in
form
atio
n
•Th
is t
ool i
s de
sign
ed t
o su
ppor
tan
d em
pow
er a
ll he
alth
care
prof
essi
onal
s w
orki
ng in
diff
icul
t ci
rcum
stan
ces
with
lim
ited
reso
urce
s, b
ut d
oes
not
supe
rsed
e a
deci
sion
by
an e
xper
ienc
ed c
linic
ian
abou
t w
heth
er,
whe
n or
whe
re t
o re
fer
a ch
ild.
•Th
e as
sess
men
t ap
plie
s to
all
child
ren
unde
r 16
yea
rs o
ld a
nd is
inde
pend
ent
of a
ny p
rior
or e
xist
ing
med
ical
cond
ition
.
•In
fan
ts le
ss t
han
2 m
on
ths
old
wit
h in
crea
sed
res
pir
ato
ry r
ate
and
ste
rnal
rec
essi
on
sh
ou
ld b
e re
ferr
edp
rom
ptl
y to
th
e n
eare
st h
osp
ital
bec
ause
th
ey a
re a
t h
igh
ris
k o
f su
ffer
ing
sev
ere
illn
ess
or
dea
th.
•Fe
ver
alon
e is
not
use
d as
a c
riter
ion
for
refe
rral
to
hosp
ital i
n ch
ildre
n ov
er 3
mon
ths
of a
ge,
as it
is a
poo
rdi
scrim
inat
or f
or s
ever
e ill
ness
.
•D
iffic
ulty
in f
eedi
ng in
dica
tes
a ne
ed f
or a
sses
smen
t bu
t is
not
by
itsel
f a
good
mea
sure
of s
ever
eill
ness
.
•W
hen
refe
rral
is n
ot in
dica
ted,
a c
opy
of t
he h
ome
care
adv
ice
leaf
let
shou
ld b
e pr
ovid
ed,
with
enc
oura
gem
ent
to c
all a
gain
sho
uld
the
child
’sco
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 c
hild
ren
on a
rriv
al a
t ho
spita
l.
The
Swin
e Fl
u Pa
edia
tric
Com
mun
ity A
sses
smen
t To
ol is
end
orse
d by
: The
Roy
al C
olle
ge o
f G
ener
al P
ract
ition
ers,
The
Roya
l Col
lege
of
Paed
iatr
ics
and
Chi
ld H
ealth
, Th
e Ro
yal C
olle
ge o
f N
ursi
ng,
The
Roya
l Col
lege
of
Mid
wiv
es,
The
Col
lege
of
Emer
genc
y M
edic
ine,
The
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
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. I
t w
ill a
ssist
with
dec
idin
g w
heth
er a
sic
k fe
brile
chi
ld w
ith f
lu-li
ke il
lnes
s ne
eds
refe
rral
to t
he n
eare
st g
ener
al h
ospi
tal E
mer
genc
y D
epar
tmen
t. M
ost
child
ren
are
expe
cted
to
be m
anag
ed in
the
com
mun
ity.
Res
pir
ato
ry f
ailu
re,
ove
rwh
elm
ing
gas
tro
ente
riti
s, s
ho
ck,
hea
rt f
ailu
re a
nd
en
cep
hal
itis
are
th
e m
ost
lik
ely
mo
des
of
crit
ical
illn
ess
in c
hild
ren
su
ffer
ing
fro
m s
win
e fl
u.C
ompl
icat
ions
suc
h as
sep
sis
and
men
ingi
tism
ay c
o-ex
ist.
Cri
teri
aR
EFER
CH
ILD
REN
TO
TH
E N
EAR
EST
GEN
ERA
L H
OSP
ITA
L EM
ERG
ENC
Y D
EPA
RTM
ENT
IF
lab
elTH
EY P
RES
ENT
WIT
H A
NY
OF
THE
FOLL
OW
ING
:
ASe
vere
res
pir
ato
ry d
istr
ess
Low
er c
hest
wal
l ind
raw
ing,
ste
rnal
rec
essi
on,
grun
ting,
or
nois
y br
eath
ing
whe
n ca
lm.
BIn
crea
sed
res
pir
ato
ry r
ate
mea
sure
d ov
er a
t le
ast
30 s
econ
ds.
≥50
brea
ths
per
min
ute
if un
der
1 ye
ar,
or ≥
40 b
reat
hs p
er m
inut
e if
≥1ye
ar.
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
or
apn
oei
c ep
iso
de
Apn
oea
defin
ed a
s a
≥20
seco
nd p
ause
in b
reat
hing
.
EEv
iden
ce o
f se
vere
clin
ical
deh
ydra
tio
n o
r cl
inic
al s
ho
ckSt
erna
l cap
illar
y re
fill t
ime
>2
seco
nds,
red
uced
ski
n tu
rgor
, su
nken
eye
s or
fon
tane
lle.
FA
lter
ed c
on
scio
us
leve
lSt
rikin
gly
agita
ted
or ir
ritab
le,
seiz
ures
, or
flo
ppy
infa
nt.
GC
ausi
ng
oth
er c
linic
al c
on
cern
to t
hei
r o
wn
GP
or
clin
ical
tea
me.
g. a
rap
idly
pro
gres
sive
or
an u
nusu
ally
pro
long
ed il
lnes
s.
Swin
e fl
u p
aed
iatr
ic c
om
mu
nit
y as
sess
men
t to
ol
For
use
in
all
child
ren
un
der
16
year
s o
ld i
n t
he
com
mu
nit
y.
Furt
her
in
form
atio
n
•Th
is t
ool i
s de
sign
ed t
o su
ppor
tan
d em
pow
er a
ll he
alth
care
prof
essi
onal
s w
orki
ng in
diff
icul
t ci
rcum
stan
ces
with
lim
ited
reso
urce
s, b
ut d
oes
not
supe
rsed
e a
deci
sion
by
an e
xper
ienc
ed c
linic
ian
abou
t w
heth
er,
whe
n or
whe
re t
o re
fer
a ch
ild.
•Th
e as
sess
men
t ap
plie
s to
all
child
ren
unde
r 16
yea
rs o
ld a
nd is
inde
pend
ent
of a
ny p
rior
or e
xist
ing
med
ical
cond
ition
.
•In
fan
ts le
ss t
han
2 m
on
ths
old
wit
h in
crea
sed
res
pir
ato
ry r
ate
and
ste
rnal
rec
essi
on
sh
ou
ld b
e re
ferr
edp
rom
ptl
y to
th
e n
eare
st h
osp
ital
bec
ause
th
ey a
re a
t h
igh
ris
k o
f su
ffer
ing
sev
ere
illn
ess
or
dea
th.
•Fe
ver
alon
e is
not
use
d as
a c
riter
ion
for
refe
rral
to
hosp
ital i
n ch
ildre
n ov
er 3
mon
ths
of a
ge,
as it
is a
poo
rdi
scrim
inat
or f
or s
ever
e ill
ness
.
•D
iffic
ulty
in f
eedi
ng in
dica
tes
a ne
ed f
or a
sses
smen
t bu
t is
not
by
itsel
f a
good
mea
sure
of s
ever
eill
ness
.
•W
hen
refe
rral
is n
ot in
dica
ted,
a c
opy
of t
he h
ome
care
adv
ice
leaf
let
shou
ld b
e pr
ovid
ed,
with
enc
oura
gem
ent
to c
all a
gain
sho
uld
the
child
’sco
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 c
hild
ren
on a
rriv
al a
t ho
spita
l.
The
Swin
e Fl
u Pa
edia
tric
Com
mun
ity A
sses
smen
t To
ol is
end
orse
d by
: The
Roy
al C
olle
ge o
f G
ener
al P
ract
ition
ers,
The
Roya
l Col
lege
of
Paed
iatr
ics
and
Chi
ld H
ealth
, Th
e Ro
yal C
olle
ge o
f N
ursi
ng,
The
Roya
l Col
lege
of
Mid
wiv
es,
The
Col
lege
of
Emer
genc
y M
edic
ine,
The
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