As those lucky enough to be under the age of 25 return to schools, universities, and group events, the novel H1N1 virus has begun to spread and generate headlines in America again. Don’t call it swine flu, although I liked all the jokes and cartoons. Too much misperception using that term, and the pork producers noted a very marked reduction in their business! Most importantly, the public feared contact with swine or swine products, rather then the person sneezing next to them.
In no time, it has begun to affect large numbers of people, with an infectious pattern likely to mimic that of the spring. What cannot be predicted is the severity of the disease, and possible mutations of the virus that would lead to a high mortality rate. The vaccination is in safety testing, and the development of dosing and widespread administration programs. It is in shorter supply then was expected. When it comes available, the priorities for immunization will be:
•Children and staff in childcare centers and schools (K-12)
•Pregnant women, young children, household contact of children <6 months of age
•Young persons with underlying medical conditions (asthma, congenital heart disease, diabetes, chronic lung diseases)
•Health care workers
There will be an urgency to get the seasonal influenza vaccine, particularly for health care workers. Some hospitals and health systems are “mandating” that the staff members will all be vaccinated for the seasonal flu.
This brief window gives the ED Leader an opportunity to prepare management plans that would address an outbreak with increased volume related to the flu, or increased acuity and volume. This planning program should include elements for logistics, medical care delivery, communications, and protection of staff members.
This can’t be taking place at a more challenging time. Every hospital, ED, and public health agency in the nation is facing budget constraints. Volumes are up, and it is predicted that payor mixes may begin to deteriorate. Unless properly protected and educated, it is also possible that health care workers will be afraid to report for duty.
Addressing the Challenges of H1N1 as an ED Leader
•Plan more meetings. If you plan ahead, these meetings can be very productive and focused
•Develop written plans. Committing plans to paper will consolidate the thoughts of the needed parties
•Broaden your sources of information by developing the link to your hospital’s infection control leaders, the local public health agency or agencies you must work with, and link yourself to immediate sources of reliable information
•Take care of yourself and your family
These challenges can be met in concert with your general ED leadership duties, and be done in a cost-effective manner when merged into the planning that is done for “all hazards” in the ED and the hospital. Good planning will also set the precedent for staff protection, applying disease surveillance systems, and improving the surge capacity systems of your department.
ED leaders must step up and initiate planning
The hospital must be prepared for outbreaks of a more virulent form of the H1N1 flu. Most hospital infection control leaders are anxious to work with ED leaders to improve programs that control exposures in the ED, and allow a very efficient process of finding and reporting contagious diseases. Most EDs have faced infection control issues in the recent years, including meningococcal meningitis, community-acquired MRSA, drug-resistant tuberculosis, and SARS. If you will re-visit the materials you utilized for managing SARS patients in your ED, you will find that much of that process will apply to flu. Hospital administrators must count on the infection control staff to protect the entire institution and its workforce, and they should be more then anxious to utilize your leadership and skills in major incident response. Since the ED is the front door to the hospital and the source of the majority of admissions, there is great benefit to having the ED staff be initiators of programs on use of Personal Protective Equipment (PPE); applying a universal respiratory etiquette program to all persons coming through the front door to the ED; reporting on potential or actual cases; and developing care pathways that are based on the best information available on screening and providing treatment. ED leaders cannot be passive in dealing with hospital infection control, or they are forcing hospital administration to be working around, rather then with, the ED.
Hash out details at your ED staff meetings
At staff meetings, work to develop a PPE plan that is affordable and workable for your staff. It will need to differentiate routine patient interaction with those patient interactions that are “aerosol-generating”, where higher level protection will be needed. Work on logistic and staffing plans. Do you have 3 or 4 backup sources laid out for critical items, particularly personal protective equipment? Will your patient greeting program be adequate if it starts at the front door to the ED, or does it need to move outside? Does your signage provide instructions appropriate for your patients and families, including all necessary languages? What screening techniques will be used, and can your lab accommodate the specimens? How will you report positive results, to patients, your hospital infection control, and to the public health authority? Very importantly, do you have 5 backup sources laid out for critical staff members? The doors cannot close even if a large number of your staff members (or their children) are ill. What is your plan to screen staff members for an illness as they arrive for duty or work a long shift? Can illness that is concentrated in an important group of practitioners be covered by others on your staff? What would you do if the illness struck a large number of respiratory therapists, phlebotomists, X-ray techs, security personnel, or clerks?
Take a moment for a SARS refresher
If you want a chilling reminder of how staffing can be effected, read the recounts of Prince of Wales Hospital in Hong Kong during the SARS outbreak. Their daily staff meetings included a count of which members had just died in the last 24 hours, or had just been diagnosed with that deadly respiratory virus. They shared stories of their families moving away from the city, and how no one would sit or stand near them on the subway.
Prepare your staff for proper vaccination
Develop the program elements for staff protection and reporting. Keep up to date on the availability, timing, and distribution mode for the H1N1 vaccine, and for the regular seasonal flu program. ED staff members have been placed high on the priority list. Prepare your staff for immunization with appropriate vaccines, and perhaps even assist your Public Health provider by having staff serve off-duty as vaccination personnel. Most communities need more of these resources. Develop an accountability program for illness reporting by staff during an outbreak, so you can be aware of the impact on your personnel. It would also be timely to develop a program for staff member isolation, and recovery, for those that do get ill. It is unlikely that quarantine principles will be applied in this outbreak, as the disease is, and will be, too widely disseminated to effectively manage with that process.
Share the load and stay organized
To keep your internal ED staff planning meetings manageable, split the background homework among as many staff members as can assist, and hold them to tight timeliness. Borrow liberally from CDC documents, and from those you share with your local hospitals and EMS providers. Ask a reliable staff member to be the secretary, sergeant at arms, and responsible party to assemble the needed documents. Take any notes and documents and post them to your staff, so they know how you are working on their behalf. If you have a very large ED staff, use the opportunity to create a newsletter for information dissemination. And post a bulletin board and envelope asking for suggestions!
Create a global game plan
For those EDs farther along in the planning process, consider producing a modular Continuity of Operations (of COOP) plan for the ED. This will allow you to apply scaled measures, with triggers, that will more efficiently address the department’s needs. Examples of COOP plans are available from many local businesses, particularly those with an essential mission like an emergency department has. And have one of the staff account for the costs of performing the planning and purchasing needed resources. At some point, it is likely that an administrator will need to tally the costs of the planning program.
Insure a regionally cooperative effort
Your meeting schedule must include the necessary links to the local public health agencies providing service in the region of this ED, all EMS providers with services relative to this ED, and the other regional hospitals. This MUST be a regional cooperative effort! Some Public Health agencies have already been aggressive, and started facilitating these regional meetings. If so, the ED leader has an opportunity to work within that group to insure program elements that address ED needs. Make sure to include EMS in any planning related to the care of emergency patients. The use of PPE, nebulizers, patient masks, and guidance for follow-up care must be consistent between the prehospital providers and the ED staff. Try to imagine the day the first patients are delivered to your ED by EMS providers that are dressed in masks, goggles, and gowns, and your staff has no PPE in place!
Work with the media whenever possible
Take every opportunity to work with the local media on health care stories. Use those news reports to remind people to wash their hands and cover their mouths when they cough. Build the bridges now with your hospital communication staff and members of the local media. Infection control stories are very complex, and require the best communicators to convey a clear message to the community. Develop the releases and the speakers that can do that, and make sure their message is consistent with releases from the CDC and state/local health agencies. Provide the local media with the CDC documents and releases.
When it is appropriate, have all the community’s ED and EMS leaders release consistent statements, or appear at a joint press conference, about how each is applying the same management principles, and sharing information that allows the emergency system to be as effective as possible.
Stay current through CDC updates
You must broaden your sources of timely information related to the flu. There are several links available to immediate sources of reliable information. As you finish this article, and before you shut down your computer, sign up for COCA updates through the CDC. This site is one which allows regular (at least weekly) news briefs to come to your e-mail box. They are brief, and highlight any critical information or programs that have become available across all areas of public health. Recent briefs have been heavily weighted to preparing for the novel H1N1 influenza. Another daily source of information is available through www.cdc.gov/h1n1flu/whatsnew. This site must be accessed by you to find out what new documents, policies, or announcements have been posted (on a daily basis) across the CDC related to novel H1N1 influenza. This site has a number of references useful for leaders, and also allows you to sign up to get notified on an hour by hour basis of any new documents posted related to flu.
The general sites: cdc.gov
are also worthwhile sources of information that are shared across the general public.
Don’t forget your own health
Finally, it is critical that emergency physicians and ED leaders take care of their personal health and that of their family members. Get the seasonal flu vaccine, get appropriate rest and exercise, and as appropriate, get the H1N1 vaccination as it comes available. Utilize great infection control practices everyday, to keep yourself safe from all contagious diseases that move through the ED, and those that you could take home to your family. This preparation and habit of good practices will allow you to be confident as any form of contagious disease becomes concerning, and able to reassure your family you will stay healthy and not bring any bugs home to them. It also “leads by example” to all of the staff members counting on you to deliver the service your community needs from the ED.
How bad will it get? We have really seen this virus can spread easily, particularly in the young people. A small change in virulence, and we have a very dangerous situation for the planet. In our organization, we are developing two levels of programs. The widespread but low acuity plan, which will mean a busy fall and winter in the ED, but little change in life. The high level plan calls for changes in society, and our assistance to the Medical Examiners’ office. In 30 years, I haven’t written one of those plans before.