Web Exclusive: H1N1 Flu Scare Provides Practice for Pandemic Operations
Tuesday June 2, 2009
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For the most part, healthcare workers say both public and private health systems passed the test, though they reported small surprises, glitches, and gaps they plan to fix for the next time they encounter H1N1 flu or any other public health emergency.
“I learned that we were pretty good,” says Connie Moore, RN, MBA, CIC, infection preventionist manager at University Medical Center in Tucson, Ariz., echoing comments of infection control and ED nurses across the country. “We were prepared. We had our ducks in line.”
Though public health officials caution the first bout of H1N1 flu is not over, so far the virus has caused relatively few hospitalizations and far fewer deaths than seasonal flu viruses, according to the U.S. Centers for Disease Control and Prevention. Most hospitalizations and deaths have occurred in people with health conditions such as diabetes or pregnancy.
In a recent press conference, Thomas R. Frieden, MD, New York City’s health commissioner, said hospitals there that normally get 200 visits a day have been getting more than 2,000 a day. In the month of May, 25,000 people visited the ED, he said. Freiden attributed the increasing numbers of ED visits in part to publicity over four deaths in the city attributed to flu, but also to the spread of the illness in the general population. Of those who visited the ED, fewer than one in 50 were admitted to the hospital, he said.
Except for New York, New Jersey, and New England, reports of new flu cases around the country have tapered off, and hospital visits for flu symptoms have dropped to normal levels, according to CDC officials.
“This has been an extremely interesting learning experience, as well as a good practice run for what might be happening in the future,” says Alex Tomich, RN, MSN, an infection control practitioner at Loyola University Health System in Chicago.
The week of April 26-May 2 had the highest number of visits to the Loyola ED since Jan. 1, and by far the highest number of flu-like illnesses. There were 1,360 visits, 74 of which were for flu symptoms. Two weeks before, when the flu season was tapering down (April 12-18), total ED visits were 1,189, with seven due to flu-like symptoms.
Initial Reaction
Within hours of reports of an unknown virus detected in patients in Southern California and Texas that was possibly related a new flu responsible for deaths in Mexico, hospital workers and health departments across the country began holding meetings and poring over emergency plans, preparing for worst-case scenarios.
Did they have enough supplies? How would they keep people calm? How would they organize patient flow and screening of potentially sick people? How would they keep staff informed and up-to-date? What precautions would they put in place to protect workers? How would they operate if large numbers of people called in sick?
To control the influx of sick patients and “worried well” expected once H1N1 flu became headline news, University Medical Center set up a tent outside the ED where patients who feared they had the new flu were asked to put on masks and fill out questionnaires describing their symptoms. A physician decided who would be cultured, and those with mild symptoms were tested and sent home, Moore says.
Other hospitals used hallways and conference rooms to separate suspected flu cases from other patients, and had tents and other temporary structures ready in case patient flow increased dramatically.
At Massachusetts General Hospital, Boston, an ED “greeter” nurse asked questions, handed out masks, and directed suspected flu patients to screening rooms. The hospital created a second pediatric waiting room for children who might have H1N1 flu. Children made up the majority of possible cases, says Maryfran Hughes, RN, MSN, nursing director of the ED there.
Texas Children’s Hospital in Houston, where the first H1N1 flu death was reported, set up a four-way triage system in a covered parking area, dividing patients into low- and high-acuity possible flu cases, and low- and high acuity non-flu patients; each child was given a colored armband according to his or her condition.
On a peak day, the ED handled 360 children in 24 hours — about 135 more than usual, says Gail Parazynski, RN, BSN, clinical director of the emergency center at Texas Children’s.
Low-acuity flu patients “were seen quickly and efficiently and never entered the main hospital,” she says. Most were children whose parents were nervous about coughs or sniffles and needed reassurance and information.
“Parents want to see a provider. They don’t care how it happens,” Parazynski says.
Public Education
To help reassure the public, hospitals set up systems to keep people educated and up-to-date on H1N1 flu before they entered the ED. Some created special hot lines and Web pages.
In the San Diego area, which had some of the earliest cases in the country, Scripps Memorial Hospital in La Jolla worked with county and state health officials to print a variety of educational materials with information about hand hygiene, flu symptoms, and basic things people could do to keep themselves healthy. They set up the information on tables outside the ED.
“We kept printing them because they went like hotcakes,” says Vicki Bradford, RN, director of emergency services at Scripps Memorial. “It was a wonderful opportunity to educate patients and families.”
People were concerned and anxious, she says, but there was never a mob scene or demands to be seen or receive medication.
Over the weekend after H1N1 flu news broke, Loyola University Health System in the Chicago area set up a special Web site for staff and the public, with links to CDC reports, case definitions, treatment options, a list of frequently asked questions, and other information, Tomich says. Loyola’s emergency team also talked about contingency plans for staff shortages if workers called in sick or had to stay home because of school closings.
At many hospitals, infection control specialists met regularly with hospital employees to answer questions and talk about ways they could protect themselves, such as using masks and other protective equipment.
“That was extremely reassuring to the staff,” says Mary Ellen Doyle, RN, vice president and chief nursing executive at Scripps Memorial.
Despite initial confusion and lack of knowledge about the new virus, hospitals reported few absences in the first weeks after H1N1 flu became known. If anything, ED nurses say, they received extra help from unlikely areas of the hospital — not only other clinicians, but administrators, clerks, marketing people, and others who pitched in to register patients, run supplies, direct traffic in the parking lot, and set up information tables.
“The collaborative effort was huge,” Parazynski says. “We learned that in a pandemic we [would be] able to turn something on very quickly and have it run very successfully. A plan that we had in place worked.”
Patching Holes
Not everything worked perfectly, however. Nurses and hospital administrators say they will continue debriefing, examining emergency plans in coming weeks, and patching any holes.
Emergency planners at Scripps Memorial found themselves caught somewhat off-guard by decisions to close schools where cases of H1N1 flu were reported. They had a contingency plan for employee day care in the event of a terrorist attack or natural disaster, but during an epidemic, the point of school closures is to keep children from gathering together. Fortunately, school closures did not affect children of the hospital staff, but it is something hospital planners will discuss and plan for in the future, Doyle says.
Some hospitals found themselves short of items, such as antibacterial hand sanitizer, and are working with vendors to make sure supplies are ready next time. Some are tinkering with screening protocols and looking for ways to improve patient flow. At Mass General, healthcare workers have decided to look for ways to offer treatment as part of the screening process, so people who test negative for flu won’t have to return to the regular ED to be seen, Hughes says.
As public concern has waned, many hospitals have dismantled tents and special triage areas set up to handle suspected cases, and are now limiting H1N1 flu testing to specific patients, in accordance with CDC guidelines.
But if H1N1 flu returns in the fall in a more virulent form, nurses say they are prepared to deal with it. They say they will be watching CDC and World Health Organization reports closely to see how the virus evolves in the Southern Hemisphere, where cooler temperatures will allow seasonal flu viruses to thrive. They will be reading accounts of possible virus mutations. They will inventory equipment, identify possible isolation areas, and keep workers informed about emergency plans and protection protocols.
“We now have four or five months to fine-tune the emergency plans that we have in place,” says Linda Good, RN, PhD, a manager for employee and occupational health at Scripps Memorial Hospital. “I think we’ll be as ready as we can.”
Cathryn Domrose is a staff writer for Gannett Healthcare Group.
To comment, e-mail editorNTL@gannetthg.com.
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