Other Voices
Planning for a Pandemic
By Haydn Bush
Public health officials caution that as many as 40 percent of Americans could be stricken with the H1N1 virus over the next two years and hundreds of thousands of people could die if vaccine campaigns and other protective measures aren't followed.
Deborah Levy, chief of Healthcare Preparedness Activity for the Centers for Disease Control and Prevention, says hospitals should be working now to improve lines of communication with local public health departments, vaccine manufacturers and states to adequately prepare the proper supplies and protocols. That could go a long way toward repeating scenes from last spring when hospital emergency departments were flooded with potentially infected patients and their families. Hospitals had to scramble to meet increased demand. Levy spoke with Staff Writer Haydn Bush.
What should hospitals be going right now to prepare for the potential return of H1N1 this fall?
They definitely need to plan for surge capacity because there is the concern [H1N1] will come back in a stronger way this fall and there will be more cases. We have no way of knowing for sure how the virus will come back in the fall, which is why the CDC is watching what's happening in the Southern Hemisphere—but if it continues to hit the same demographics, then a lot more attention to pediatrics and young adults is needed. The pediatric hospitals got pushed quite a bit during this not-ultra-severe pandemic. A lot of times, pediatricians and pediatric hospitals don't focus on influenza as much. It's still sometimes seen as an older person's disease.
Was that something providers weren't prepared for last Spring?
It's not that they weren't exactly prepared for it, but I don't think the preparedness was specifically targeted to a surge in younger adults and children. Because children don't just automatically go to any hospital, you try and take them to pediatric hospitals, and this fall that could put a bigger burden on those hospitals.
Were there supply shortages?
There were different rumors. It's hard to say what exactly was really true and what different groups were putting out there, but we started getting a lot of messaging around "Oh well, we can't give you more supplies because we're holding them for the federal government," which was incorrect. We made it clear that was not what we were doing. The rumors tended to be across the board, a lot on medical supplies, but we even saw some of that with diagnostic kits.
The language sometimes gets confusing. When you hear there's a shortage, is it really a shortage, or is it just that you want more than what was planned? There wasn't a shortage this time, and yet we continually heard there was. Most states didn't end up having to dig into their stockpile. The CDC pushed out 25 percent of the stockpile to the states. It was sufficient, and yet you kept hearing about shortages.
How do you build surge capacity?
If you're planning by yourself in a silo, that is not the right approach. Hospitals need to work with their clinicians, other hospitals in the community and other components of the health care sector. You're trying to use all the resources in your community so you don't have everybody rushing to the hospital. Hospital emergency departments [last spring] got overwhelmed in some cases. It was parents bringing their children in who might not have been really severely ill, but they were coming in saying, "I want you to check my child out."
If H1N1 was not happening and your child had a sore throat, you'd tell them to stay in bed and give them two Tylenol and that would have been the end of the story. Because H1N1 was circulating around, now suddenly your child has a temperature and you think, "Oh my God it's H1N1, I need to have my child tested" and off you go [to] the ED.
Who should hospitals work with?
They need to get the messaging straight. Work with public health, because public health is going to do a lot of directing and messaging. In severe cases, if you haven't done any kind of planning with emergency management, that's a problem. Think about an ice storm or a tornado coming through. Which group within your community helps manage that incident and helps with resources? It's emergency management. They don't necessarily understand the details of what goes on in a hospital and in the clinics that support the hospital. Those dialogues shouldn't start happening in the middle of an incident.
When we work with communities and conduct workshops, we require about 15 sectors to show up. We work with them to think about the model of care delivery—everything from supplies down to managing your staff and your beds. How do you reduce demand, and once you're in the hospital how do you deal with a surge?
We want 911, other urgent call centers, EMS, emergency departments and hospital administrators, your private providers, clinic officers, outpatient and other urgent care clinics, public health, emergency management, hospice, long-term care, palliative and pharmacies involved. If you want to do your ideal planning to respond to H1N1 or any other scenario, all of those folks should be at the table.
You still need a core team within that, and that's where we put health care, public health and emergency management as the triad to drive the planning. In case of a full-blown pandemic, will hospitals have enough beds or need to find additional space to house patients? You may end up having to think about cohorting patients. As patients come into the emergency room, it's not like you're just going to have H1N1. If you do end up having a lot of the mildly ill still trying to get into the hospital, you really don't want them exposing their illnesses to your other, chronically ill patients. Thinking about how you would do that initial triage when all of these patients are trying to get into your facility is really important. And then it's important to think about where you put all these patients in hospitals.
What about supplies?
Clearly, you need your infection control materials. There's always the possibility if the virus changes that you would have bacterial infections over and above what you're getting with the flu. It's also the chronic disease medications and the things that people tend to run out of.
Facilities need to make sure they understand what their state and local public health department is going to do with the stockpile. When the CDC arrives and turns it over to the state, that's it. Each state has a different strategy. The lesson is, don't start to ping the public health department in the middle of the surge. You should have that all figured out already. Know what's happening to the stockpile, and also know what you're not getting.
Sometimes, there's also a false assumption that you don't really need to get all of these materials because in a push, you think you'll get it in from the stockpile. That was never the intent of the stockpile, to support pandemics indefinitely.
How much flexibility should hospitals build into their response plans?
They should go back and see how their plans lined up with what happened with H1N1. For some of the states and some facilities, it didn't go the way they thought it was going to go. Everybody thought a pandemic would begin overseas, and so you would have X amount of weeks to prepare for its arrival in the United States. Plans need to outline everything, but they shouldn't be rigid. You need to look at what went well and what didn't go well, and then start making changes. Part of what allows flexibility is to build in triggers to implement certain aspects of the plan. That way, you can watch what happens and when it hits a certain trigger, then you need to implement it.
This article 1st appeared in the September 2009 issue of HHN Magazine.
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