Are any of your patients getting tested for swine flu?

Nurturer3 · May 10, 2009

At my hospital we are asking screening questions of every patient. If they answer yes to two or more of the 6 screening questions, then they must be tested for H1N1.

indigo girl · May 11, 2009

About that testing...

http://www.recombinomics.com/News/05100902/Swine_H1N1_NY_HS.html

...there is concern that the swine H1N1 is still silently spreading (see updated map), because the vast majority of cases are mild, and require enhanced surveillance for detection, although a simple influenza A test will be more predictive of swine flu as the seasonal flu season ends in the northern hemisphere.
The above announcement by the NY lab has been echoed across the country. The testing will be selective, and a complete picture of the H1N1 spread will be lacking. This focus on the more severe cases mimics confirmations in Mexico, where the lab confirmed cases significantly underestimates the level of infections.
The focus on severe cases increases the case fatality rate. In the US there have been three reported H1N1 deaths and there has also been a death in Alberta , Canada, raising concerns that the number of fatal infections will climb significantly over the near term.
The identity between H1N1 in Mexico and the US (as well as all other countries submitting sequence data - see list of isolates here), raises concerns that the silent spread will produce frequent co-infections between swine and seasonal H1N1. These co-infections can produce genetic exchanges between human and swine isolates via reassortment and recombination.

This type of rapid genetic evolution between human and swine H1N1 raises concerns that a more virulent H1N1 will emerge in the near term, and lead to a significant rise on severe cases in the fall, when the flu season begins in the northern hemisphere.

Maine17 · May 11, 2009

Many of the school nurses in my state have been expressing concern that students that have been sent home ill from school with symptoms that could possibly be swine flu are not being seen by their physicians and not staying out for 7 days. The result is (probable) lots of spreading of this virus, with most of the cases being mild. Concern is for students/staff that are immunosuppressed etc. I believe we will see an increase in more severe cases due to this lack of surveillance.

lamazeteacher · May 12, 2009

So, we could have a lot more cases in the U.S. I don't get why they aren't screening anyone with fever and chills for the swine flu.
I haven't heard much talk at work about it, other than making fun of the whole thing.

I went in to be tested when I developed s/s of flu last week, a week after my discharge as a patient, from hospital. They did a throat swab and immediate results were negative. The doctor said that positive results are more likely on the 3rd or 4th dsy of illness (I was on day 2), yet Tamiflu is most successful when administered within 48 hours of being symptomatic.

Not testing for any infection interfers with timely diagnosis, but in this case, waiting another day would cause a delay in treatment that could be dangerous. I was treated "as if", as many others are.

I happened to pick up an issue of JAMA's Mar. 11 '08 issue at my doctor's waiting room today, for a post hospital follow up (which I postponed for 3 days, until my Tamiflu finished, and wore a mask in case of coughing)

There were 2 excellent articles about nosocomial A/H1N1 cases. Of 4 high risk cases, 2 died. All went into isolation, but too late, as exposure of staff and other patients had occurred. 5 staff members became ill on the same day, 4 days after patients came to their unit, and 1 staff member became ill the 3rd day, another the 5th day. Only one of the high risk patients had been vaccinated against the flu, but still got the A/H1N1 with that exposure. It makes one wonder, doesn't it?

When I worked as an Infection Control nurse, I was always taking cultures that physicians hadn't done, before the antibiotics empirically given had time to work. There seems to be a huge gap in medical school education and practise which deters all types of cultures from being done, due to the usual 2 day process of them. However now instant results of flu virus and strep are possible.......

It would be very helpful if nurses suggested to doctors, whose symptomatic patients are on their unit, that an order for an oral swab test be taken........ like this, "here's a swab that might reveal H1N1 for your patient in room _____ I'll take it if you order it".........

Medic04 · May 12, 2009

I had a patient who had been admitted with fever and SOB yesterday, he also had an extensive cardiac history, was diabetic of course, and other factors. I looked on his labs from this stay, no sign of any of any screening for flu. I wondered why on earth, with all this hubbub, this guy wasn't getting tested for swine flu. There have been a few cases in my state and our area has a large Mexican population. The wife even mentioned it to me after I had already been wondering about it to myself. He was basically admitted with flulike symptoms, and being treated for pneumonia.
Any of your patients being tested?

It seems like every patient that comes to the ER is tested these days.

The funny thing, if there is a + flu they have no clue in house which mask to wear, each ADON gives a different answer.

lamazeteacher · May 12, 2009

It seems like every patient that comes to the ER is tested these days.
The funny thing, if there is a + flu they have no clue in house which mask to wear, each ADON gives a different answer.

From reading some of the CDC references given by Indigo girl, I recall that the regular surgical mask was recommended for patients with swine flu (or suspected swine flu), to avoid microbial "spraying" when they cough or sneeze. N95 respirator/masks (properly fitted) need to be worn by staff working with them, as it's necessary to filter out the small virus with that heavier duty mask. Masks should be used only once, then discarded.

Thanks, Indigo girl, for your scrupulous reporting.

RedSox33RN · May 15, 2009

I work in a fairly large ED, and anyone that is coming in with fever and one other flu sx is being tested. Until the result comes back (usually takes about 30-45 min, depending on how busy the lab is since we don't do bedside testing), we have to put the room on contact and droplet precautions. If it comes back at all pos (all positive results are then sent to state lab for H1N1 testing), we have to use our N95 respirators, and the room has to be totally disinfected before the next pt. I think I had two positive for A flu last week, but apparently is wasn't H1N1 after sent to state lab.

We are also testing *most* people for flu that come in with r/o strep throat.

twinmommy+2, ADN, BSN, MSN · May 16, 2009

I had a patient who had been admitted with fever and SOB yesterday, he also had an extensive cardiac history, was diabetic of course, and other factors. I looked on his labs from this stay, no sign of any of any screening for flu. I wondered why on earth, with all this hubbub, this guy wasn't getting tested for swine flu. There have been a few cases in my state and our area has a large Mexican population. The wife even mentioned it to me after I had already been wondering about it to myself. He was basically admitted with flulike symptoms, and being treated for pneumonia.
Any of your patients being tested?

I work in a civilian ER and a VA ER. The civilian one is testing anyone with flu like symptoms whether or not they have been in contact with a flu victim or traveled. The VA I work at is not testing regularly. We had one case come in that was possible (even though he didn't travel reciently) and there was such a hassle trying to get the swab done. The lab called down to us and stated they wouldn't do the swab unless the patient met all criteria (to include travel and contact with known cases).

oramar · May 16, 2009

I went in to be tested when I developed s/s of flu last week, a week after my discharge as a patient, from hospital. They did a throat swab and immediate results were negative. The doctor said that positive results are more likely on the 3rd or 4th dsy of illness (I was on day 2), yet Tamiflu is most successful when administered within 48 hours of being symptomatic.
Not testing for any infection interfers with timely diagnosis, but in this case, waiting another day would cause a delay in treatment that could be dangerous. I was treated "as if", as many others are.
I happened to pick up an issue of JAMA's Mar. 11 '08 issue at my doctor's waiting room today, for a post hospital follow up (which I postponed for 3 days, until my Tamiflu finished, and wore a mask in case of coughing)
There were 2 excellent articles about nosocomial A/H1N1 cases. Of 4 high risk cases, 2 died. All went into isolation, but too late, as exposure of staff and other patients had occurred. 5 staff members became ill on the same day, 4 days after patients came to their unit, and 1 staff member became ill the 3rd day, another the 5th day. Only one of the high risk patients had been vaccinated against the flu, but still got the A/H1N1 with that exposure. It makes one wonder, doesn't it?
When I worked as an Infection Control nurse, I was always taking cultures that physicians hadn't done, before the antibiotics empirically given had time to work. There seems to be a huge gap in medical school education and practise which deters all types of cultures from being done, due to the usual 2 day process of them. However now instant results of flu virus and strep are possible.......
It would be very helpful if nurses suggested to doctors, whose symptomatic patients are on their unit, that an order for an oral swab test be taken........ like this, "here's a swab that might reveal H1N1 for your patient in room _____ I'll take it if you order it".........

In my clinical experience I have observed all the lax behaviors you describe here. I did a post once where I suggested that in my county anyway, all positive swabs require paper work by the physician to the health department. I really think they don't want to get a positive culture because they don't want to do the paper work.

lamazeteacher · May 16, 2009

The lack of testing, and getting false negatives when tests are done before day 3 or 4 of onset, blocks statistical analysis of the situation. If it wasn't so much work, decontaminating the room and possible exposure of other patients wasn't the problem it is, I'd recommend having them come back after the 3rd or 4th day, for the test. However, if you don't give Tamiflu by 48 hours after onset, that will impose risks of causing deterioration

of their condition.

We need to know if the administration of Tamiflu causes a negative result on days 3-5. It would also be great if home test kits were available to give patients after instructing them to avoid contamination of swab and puting it as far back in the nares as possible (not so far as to cause damage/ epistaxis, however).

lamazeteacher · May 16, 2009

In my clinical experience I have observed all the lax behaviors you describe here. I did a post once where I suggested that in my county anyway, all positive swabs require paper work by the physician to the health department. I really think they don't want to get a positive culture because they don't want to do the paper work.

Actually the Infection Control nurse gets the pos. results (if the test is done at a hospital) and completes the scanty paper work. If your MDs don't know that, please tell them!

indigo girl · May 16, 2009

We need to know if the administration of Tamiflu causes a negative result on days 3-5.

Are you thinking of doing a second test after a positive PCR? Given that less testing is now being done, I do not think that this will happen.