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Influenza Screening and Treatment – Adult/Pediatric – Ambulatory [133]

Influenza Screening and Treatment – Adult/Pediatric – Ambulatory [133] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 133

Delegation Protocol Title:
Influenza Screening and Treatment – Adult/Pediatric – Ambulatory

Delegation Protocol Applies to:
Primary Care Clinics including Internal Medicine, Family Medicine and Pediatrics,
Geriatrics, Obstetrics, Healthline, Transplant

Target Patient Population:
Patients 5 years of age and older with symptoms suggestive of influenza and who are at high risk
for influenza-related complications

Delegation Protocol Champions:
Jon Temte, MD, PhD - Department of Family Medicine
Sandy Kamnetz, MD - Department of Family Medicine
Betsy Trowbridge, MD - Department of Internal Medicine
Gail Allen, MD, - Department of Pediatrics
Nancy Fuller, MD - Department of Internal Medicine

Delegation Protocol Reviewers:
Cheryl DeVault, BSN, RN, OCN - Clinic Operations Manager – Yahara Clinic
Jill Lindwall, MSN, RN - Clinic Program Manager

Responsible Departments:
Department of Family Medicine
Department of Medicine
Department of Pediatrics
Department of Obstetrics & Gynecology
Department of Medicine - Nephrology

Purpose Statement:
This delegation protocol delegates authority from the patient’s Primary Care provider or other
UW Health specialty provider to Registered Nurses (RNs) to screen for and treat symptoms of
influenza in patients at high risk for developing flu-related complications.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RN) trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This delegation protocol is only implemented during an active flu season as determined by
UW Health Immunization Task Force based on local influenza surveillance data.
2. The protocol is initiated when the patient or their representative contacts the clinic
describing symptoms characteristic of an influenza-like illness. These symptoms include
fever of 100
o
F or higher or patient reports having a fever plus non-productive cough and/or
sore throat. Less than 48 hours have elapsed since symptoms developed for protocol to
apply.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

3. The RN will conduct a patient assessment using a scripted assessment text. The RN will use
the responses to the interview questions in combination with a chart review including
medications, allergies, problem list and past medical history to determine the appropriate
action. The patient must answer “Yes” to all questions in Step 2 and have at least one high
risk factor as outlined in Step 3 for the protocol to apply.

Step 1. Assess severity of illness – if the patient reports any of the following the protocol
does not apply. The RN will follow standard triage guidelines and/or contact provider for
next steps.
• Difficulty breathing or shortness of breath
• Constant pain or pressure in chest or abdomen
• Confusion, decreased responsiveness
• Severe or persistent vomiting
• Unable to keep liquids down
• Signs of dehydration such as dizziness when standing or absence of urination
• Experiencing seizures
• New onset of rash

Step 2. Establish history of present illness – the patient must answer “Yes” to all of the
following to continue with the delegation protocol
• Fever (100
o
F or greater in the absence of antipyretics) or patient reported
• Non-productive cough or sore throat
• Symptomatic for less than 48 hours

Step 3. Identify high risk factors for complications from influenza – the answer must be
“Yes” to at least one of the following for the protocol to apply:
• Age 65 years or older
• Ages 5 to 64 years with one of the following:
− Resident in nursing home or other long term care facility
− Diabetes
− Extreme obesity (BMI greater than 40)
− Coronary vascular disease or congestive heart failure (CHF), not isolated
hypertension
− Chronic pulmonary disease such as asthma, cystic fibrosis or chronic
obstructive pulmonary disease (COPD)
− Chronic kidney disease
− Neurologic disease that affect clearing of secretions or compromises
respiration such as cerebral palsy, stroke, muscular dystrophy,
developmental disability
− Immunodeficiency; e.g. primary immunodeficiency, HIV, cancer, on
immunosuppressant medications such as large doses of steroids
(prednisone > 10 mg/day; dexamethasone > 1.5 mg/day),
immunomodulators (for example, adalimumab (Humira), etanercept
(Enbrel), tacrolimus (Prograf)) or receiving or completed chemotherapy in
past 30 days
− Sickle cell disease
− Organ transplant recipient
− Pregnancy or less than 2 weeks postpartum (Pregnancy Category C)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

− American Indian or Alaskan Native
− Age 5 through 18 years on chronic aspirin therapy
− Close contact with someone who has one of the high risk factors above.( i.e.
caregiver, cohabitation)

Step 4. Identify contraindications to the use of this protocol. If the patient has any of the
following the protocol does not apply and the provider will be consulted for next steps.
• Allergy to oseltamivir
• Previous treatment with oseltamivir during the current flu season
4. Antiviral Therapy
4.1. If the patient meets the criteria for the protocol (i.e., answers “yes” to all of the history
of present illness questions and has at least high risk factor for complications from
influenza) and does not have any contraindications to the use of oseltamivir, the RN
will order oseltamivir using dosing based on the patient’s weight. In all other cases the
RN will consult the provider before placing any orders.
4.2. Oseltamivir Dosing
Table 1. Patients less than 13 years and with normal renal function (i.e., eGFR or CrCl >
60 mL/min). For pediatric patients with known renal impairment the provider should be
consulted before placing any orders.
Weight Dose
15 kg or less 30 mg PO 2x/day x 5 days
>15 to 23 kg 45 mg PO 2x/day x 5 days
>23 to 40 kg 60 mg PO 2x/day x 5 days
>40 kg 75 mg PO 2x/day x 5 days

Table 2. Adult patients (age > 13 years) with known renal impairment (i.e., eGFR or CrCl
months), the provider will be contacted prior to placing any orders.
eGFR or CrCl Dose
>30 mL/min 75 mg PO 2x/day x 5 days
0-10 mL/min and not on
hemodialysis
Contact provider before placing any orders
Hemodialysis 75 mg PO after dialysis (no dose on non-dialysis
days) x5 doses

5. The RN will instruct the patient to contact the clinic if their symptoms fail to improve after
48 hours or worsen and provide home care advice.

Order Mode: Protocol/Policy without Cosign

References:
1. Harper SA, Bradley JS, Englund JA, et al. Seasonal influenza in adults and children - diagnosis,
treatment, chemoprophylaxis, and institutional outbreak management: clinical practice
guidelines of the Infectious Diseases Society of America. Clin Inf Dis 2009;48:1003-32.
2. Seasonal influenza (flu). Information for health professionals. Centers for Disease Control
and Prevention website. http://www.cdc.gov/flu/professionals/index.htm Updated:
December 3, 2014. Accessed: January 2, 2015.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

3. American Academy of Family Physicians. AAFP Triage Protocol for Suspected Influenza
Infection. http://www.aafp.org/patient-care/immunizations/influenza.html#h1n1. Updated:
January 29, 2014. Accessed: January 2, 2015.
4. Temte JL. Telephone triage of patients with influenza. Am Fam Phys 2009;79:943-5
5. UW Health. Treatment and Prevention of Influenza with Antiviral Medications –
Pediatric/Adult – Inpatient Clinical Practice Guideline 2015. Accessed December 10, 2015.

Collateral Documents: NA

Approved By:
UW Health Ambulatory Protocol Committee – February 2015, November 2015
UWHC Antimicrobial Use Subcommittee – January 2015 (pilot), December 2015
UWHC Pharmacy and Therapeutics Committee – January 2015 (pilot), December 2015
UWHC Medical Board – February 2015 (pilot), January 2016
UW Health Chief Medical Officer – February 2015 (pilot), January 2016

Effective Date: January 2016

Scheduled for Review: January 2019


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org