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National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza (American College of Physicians)
Purpose
This plan informs health care personnel, public
health, and government officials at all levels of the
necessary capabilities that must be present for successful
emergency department management of an outbreak of
H1N1. It also enumerates the necessary actions that must
be taken to attain these capabilities. The performance
of the necessary actions will fall to parties including
professional associations, government entities at the
federal, state and local levels, public health officials
and departments at the federal state and local levels,
and hospitals ? administrators, medical staff, nursing
and support services. Those entities should undertake
the necessary operational planning to assure their
performance prior to, during and following an outbreak
of novel H1N1 influenza. The plan serves as a guide for
emergency departments to address the interdependencies
that are necessary for successful management of such an
incident. The goal of this guidance is to protect the health
care infrastructure and ensure the delivery of emergency
medical treatment during a large scale epidemic or
pandemic.
Background
Novel influenza A (H1N1) is a new flu virus that was
first detected in April, 2009. It is thought that novel
influenza A (H1N1) flu spreads in the same way that
regular seasonal influenza viruses spread; mainly through
the coughs and sneezes of people who are sick with the
virus.1
It is uncertain at this time how severe subsequent
waves of a novel H1N1 outbreak will be in terms of
illness and death compared with other influenza viruses
or the spring 2009 wave. Because this is a new virus,
most people do not have immunity to it, and illness may
be more severe and widespread as a result. In addition,
the vaccine to protect against novel H1N1 virus is not
expected to be available until after the onset of a fall 2009
wave. Therefore, health care institutions broadly, and
emergency departments specifically, should prepare for
high volumes of sick and contagious people seeking care.
Early indications are that pregnancy and other
previously recognized medical conditions that increase
the risk of influenza-related complications, like asthma
and diabetes, appear to be associated with increased risk
of complications from this novel H1N1 virus infection as
well. Adults older than 64 years appear to be at decreased
risk of contracting novel H1N1-related complications thus
far in the outbreak. Early reports indicate that no children
and few adults younger than 60 years old have existing
antibody to the novel H1N1 flu virus; however, about onethird
of adults older than 60 may have antibodies against
this virus.
So far, with novel H1N1 flu, the largest number
confirmed and probable cases have occurred in people
between the ages of 5 and 24-years-old. At this time, there
are few cases in people older than 64 years old, which
is unusual when compared with seasonal flu. However,
pregnancy and other previously recognized high-risk
medical conditions from seasonal influenza appear to be
associated with increased risk of complications from this
novel H1N1.
At the current time, CDC believes that this virus
has the same properties in terms of spread as seasonal
flu viruses. With seasonal flu, studies have shown that
people may be contagious from one day before they
develop symptoms to up to 7 days after they get sick.
Children, especially younger children, might potentially
be contagious for longer periods.2
Other pandemics in the 20th century have followed a
consistent pattern with multiple waves. If the pattern holds
true, the United States could see a second wave of the
disease in the early fall of 2009 into the winter of 2010.
The virus exhibited significant transmissibility during
the first wave of 2009. The virulence was more difficult
to estimate, because there was little disease surveillance
in effect at the point of the outbreak in Mexico; thus, the
prevalence of severe illness was unknown. As the disease
spread to the United States, the case fatality rate was very
low. After 20 weeks of the spring 2009 outbreak, there
were 11,054 confirmed and probable cases with 54 deaths.
Risk Awareness
Threat
If the virus follows the pandemic patterns of the 20th
century, health care providers should prepare for the
potential of higher level of virulence in the fall wave,
which occurred in both 1918 and 1957. Patterns would
suggest cases could appear in early fall and will be
occurring well into the normal seasonal flu months. If this
occurs, the population will not have had available vaccine,
and similar patterns of infection are expected, with higher
prevalence in children and young adults.
Should a second wave occur in the early fall, a vaccine
is unlikely to be available. Without vaccine, the best
defense the nation will have in reducing transmission
would be community mitigation strategies. Since case
rates are highest in school-aged children, school closures
would likely be one of the first strategies employed. This
would result in parents needing to remain home with
their children and the consequent loss of workplace
productivity. This would include healthcare workers,
reducing the ability of emergency departments and
hospitals to function at peak efficiency. An equally
important community mitigation strategy is keeping
people who are ill, even at the first sign, from entering
the workplace. Encouraging social distancing and
frequent hand washing policies are important parts of
the strategy. The combination of the effects of the disease
and employing these measures could affect the business
practices of all the critical infrastructure operators,
possibly impeding their ability to maintain normal
operations.
At some critical point, operations of hospitals are
affected, not only by the absence of its own workers, but
by slowdowns in transportation of supplies and support
services, the summary of which is the inability to maintain
normal operations, even for normal patient volumes.
If the novel H1N1 strain returns later than expected,
even with no difference in infection rate from the spring
2009 wave, it will strike concurrently with seasonal
influenza. In this case, the nation would face a higher
than normal influenza prevalence, higher work loss,
higher fatalities and the need for surge medical response.
In a typical seasonal flu season, 7% of adults and 30% of
children in an affected community may become infected
with flu virus, and much higher percentage in households
with a person who is ill. Each year, in the United States, on
average 36,000 people die from flu-related complications
and more than 200,000 people are hospitalized from
flu-related causes. Significant increases in those numbers
would be expected if the peak incidence of the two virus
strains overlap. If patterns of earlier pandemics hold true,
the second wave is more likely to exhibit higher virulence
? and thus higher case fatality rate. There is also no
assurance that antiviral medications will be effective for a
virus that has undergone selection pressure in the interim.
Each year, flu season can stress an emergency
department?s ability to maintain normal operations
because of the increase in both outpatient volume and
admissions. It is therefore prudent to prepare for a worse
than normal flu season. While the precise effects on
emergency departments to function cannot be predicted
with confidence, contingency plans should be made for a
challenging scenario.
Vulnerability
Population. No area of the United States would be
spared from the spread of novel H1N1. Although the
weather may affect transmission rates, no emergency
department is exempt from the risks of an outbreak.
If the transmission rates double from the spring 2009,
over 30,000 cases can be expected over the fall and early
winter. Emergency departments could see 150% of normal
volume of respiratory complaints. This may even be true in
communities where the novel H1N1 virus is not yet widely
present due to increased levels of concern by the public
regarding any respiratory related illness.
Critical Infrastructure. The ability of some critical
infrastructures to continue normal operations depends
largely on the attendance of its workforce. Others may
have plans and procedures in place for tele-work or social
distancing. The nation?s just-in-time supply chain could
experience delays in supplying goods and services, and
businesses who cannot survive operational interruptions
may expand inventories of supplies.
Hospitals are no exception to this. Pharmacies may
not be able to get additional supplies from distributors
or sources higher in the chain, domestic and foreign.
Supplies of personal protective equipment ( PPE) and
other supplies may require stockpiling, and food services
could encounter supply problems due to production and
delivery. The workforce may be depleted due to infection,
fears of coming to work in an infectious environment, or
the need to care for children out of school or other family
members. Medical care is highly labor intensive; thus,
service delivery is expected to be exquisitely sensitive to
the ratio of service demand to workforce supply.
Consequence. The consequences to society will
vary with the severity of the illness (transmission and
virulence), the degree to which the population is prepared
and resilient (vaccinated, compliant with community
mitigation strategies, and educated about the threat), and
whether business and industry can sustain productivity
during a pandemic. An outbreak with the severity of
the 1918 pandemic can be a nation-changing event with
massive mortality in young people who are economically
responsible for young families and, in large part, for our
nation?s defense.
Lesser-severity outbreaks can result in temporary
disruptions in the flow of goods and services, and would
likely cause further stresses on an over-burdened health
care system. Certain medical services would be delayed or
unavailable, potentially causing secondary morbidity and
mortality to those unaffected by influenza.
A mild outbreak or no change from baseline
seasonal influenza will undoubtedly result in charges
of over-reaction and fear mongering, which could have
detrimental effects on future compliance with public
health measures, future influenza immunization initiatives
and compliance with a response to public health
emergencies.
There are consequences to planning, including financial
investment and diversion of human resources, and
consequences to the lack of planning should the threat
become reality. In either case, a prudent assessment of risk
is vital and prudent planning in response to that risk is
necessary to avoid victimization.
Response to the Threat
The American College of Emergency Physicians
(ACEP) supports comprehensive response planning by
its members and their institutions. ACEP will work with
its corresponding professional associations (e.g. nurses,
prehospital professional, EMS medical directors, hospitals,
public health associations) to implement the actions and
satisfy the requirements of the planning process. ACEP
will seek support as necessary on behalf of its members
from federal government entities responsible for surge
medical response capabilities.3 ACEP state chapters
should seek the involvement of their state health directors.
Members should involve local emergency managers,
political leaders and local health directors.
The national strategic plan planning process and
the capabilities and actions herein should prompt a
local process that defines how to operationalize these
capabilities and to articulate the necessary requirements
to perform them. Those requirements should result in
the targeting of resources and the identification of gaps
that may exist in funding. Those unfunded requirements
must be communicated to local emergency managers and
political leaders to guide resource allocations and possible
supplementary grant funding from federal entities.
Emergency physicians and their professional colleagues
in nursing and prehospital care will be on the front line
of any emergency requiring surge medical response
capability. They will be the ones to answer the challenge
of waves of patients presenting for care. They will also be
the beneficiaries of good planning or the victims of the
lack of it. ACEP will exercise all of its influence to ensure
that patients can be cared for and that its members are
sufficiently resourced, trained, equipped and exercised to
fulfill their critical mission.
Triggers for various parts of a response plan are part
of the planning process, and the authorities to take
action must be clear. Likely, as cases are recognized and
increasing strain is put on acute care facilities, the health
care professionals and administrators in those facilities
will be the first to know there is a crisis. Communications
with local and state public health directors for
situational awareness is of paramount importance.
Clear communications protocols must be created and
exercised on a regular basis prior to an event. Agreements
on stepwise implementation of the relevant parts of the
plan must be in place to avoid disruptions in services
during the ramp-up phase and to allow for the necessary
provision of resources.
Just as the parts of the plan will be implemented with
the situational awareness of the local leaders and public
health officials, so will ?standing down? of the pandemic
plan. Agreements must be in place as to the triggers for
the authorities to return to the prior steady state. This
decision must be made with situational awareness of the
epidemiology of the disease in the community and cannot
be done, institutionally, in a vacuum.
Depending on the severity of the pandemic and its
virulence, institutions may face a depleted workforce.
In addition to those lost to illness, there may be those
with concerns about being in an environment of higher
risk from exposure to infectious disease. There may be
personnel who have temporary reasons for not returning
to the workplace, such as pregnancy or needing to care for
family who remain ill.
ACEP will work with its counterpart professional
associations and the federal government to dispense
actionable information to its members so that they remain
aware of current information on the changing situation
and can make decisions accordingly.
Management Strategy
ACEP will use all means necessary to (1) ensure that
our patients receive the best care possible, and (2) ensure
that its members are able to fulfill their professional
responsibilities. The National Strategic Plan for Emergency
Department Management of Outbreaks of Novel H1N1
Influenza follows the federal template for management
of biological threats, as outlined in Homeland Security
Presidential Directive #10. The pillars of that strategy are:
Threat Awareness, Protection and Prevention, Surveillance
and Detection, and Response and Recovery.
This National Strategic Plan for ED Management of
H1N1 outbreaks adapts this template to form its own
pillars of prescribed capabilities:
? Situational awareness
? Protection of the emergency department
infrastructure and personnel
? Prevention of disruptions in service delivery
? Organized, timely surge medical response
? Recovery to the previous steady state
Scenario
[This scenario is a notional planning scenario based on
available information, within which are certain assumptions
that may change as information becomes more precise. It is
meant to be challenging and realistic, but is not predictive.]
The first cases of novel H1N1 reappear in an
unspecified area of the nation in late September. Early
cases are not recognized as influenza, and will be treated
conservatively, affording the opportunity for transmission
to schoolmates and family.
The vaccine for the novel H1N1 will not be ready for
distribution in large volumes until late October. Vaccine
for the novel H1N1 may require two injections, at least two
weeks apart, to stimulate immunity. Immunity will not
be sufficient to protect subjects from infection until two
weeks after the second injection.
Local officials will be hesitant to implement community
mitigation strategies early in an outbreak, especially school
closure so close to the beginning of the school year. The
media will continue to fuel the public sentiment that
health officials over-reacted to the spring wave and are
doing likewise to the fall cases. There will be political
pressure to keep schools open because of large numbers
of workers without ?time off? benefits to care for their
children. The Federal government will not have solutions
in place, such as emergency wage replacement, to mitigate
that pressure. Because of economic pressures and high
value placed on jobs in a weakened economy, workers will
continue to work when sick, exacerbating transmission in
the most contagious stage of their illness.
After a few weeks of the fall wave, the prevalence
in affected parts of the country will increase. The first
few deaths will be reported, some in young individuals.
Emergency departments will begin to see large volumes of
people who are not ill with the flu but are concerned that
they or their children ?might have it.? They are requesting
screening and prescriptions for antivirals. Emergency
departments will experience a 150% increase in chief
complaints with respiratory symptoms.
By mid-October, 15,000 cases will be reported across
the country, with hot spots in urban areas that have not
employed community mitigation strategies. The highest
prevalence will be among children and young adults,
but during this wave, there will be a 5-fold increase in
mortality, with 250 deaths by late-October, mostly in
school-age children and those in late teens.
The CDC will document the increased virulence, and
communities will begin to close schools. Health guidance
will be provided encouraging those with fever, cold
symptoms, sore throat or respiratory symptoms to remain
at home and wear masks in public, and to go to their
doctor or the emergency department if acutely ill. This
will be concurrent with fall allergy season, when a large
proportion of people report nasal symptoms in a normal
year, and many of those will normally have sore throat
and cough. The highest concentration of people who have
no doctor or health coverage is the same population at
greatest risk for becoming ill with novel H1N1: children
and young adults.
Even though the prevalence of illness is less than 2%,
some public officials may discourage the use of public
transportation or participating in other close gatherings.
There will be increased demand on emergency medical
services for transport of patients to the hospital who would
normally see a doctor via public transportation.
As the prevalence of disease increases, deaths of
children will be in the news regardless of the case fatality
rate, and concerned parents will want their children
checked if they have any related symptoms. Primary
care providers who may have the capacity to see only a
few extra people per day, will be overbooked and will be
referring patients to the emergency department.
Planning Assumptions
1. The behavior of the virus is not predictable but is
likely to return in the fall of 2009 and persist into
2010, complicating usual seasonal flu management.
2. The fall 2009 wave will follow the pattern of
pandemics of the 20th century by having greater
virulence than the initial wave.
3. Children and young adults will experience the
highest attack rates.
4. Adults over 65 will have lower attack rates due to
previous influenza exposures.
5. The onset of the fall wave will not be detected until
after it has begun.
6. A well-matched vaccine will not be available until
mid-October 2009 at the earliest and will not be
effective until weeks after the final doses.
7. Community mitigation measures can be effective to
slow disease transmission and will be the only tool
available for prevention.
8. Mass anti-viral chemoprophylaxis will not be
recommended.
9. Continuing sensitivity of H1N1 to antiviral
medications is unknown.
10. Emergency medical and hospital planning for an
H1N1 pandemic will be successful only if it is
interoperable with emergency management and
public health.
Capabilities for Emergency Department Response
to a Severe H1N1 Outbreak
1. Trained Emergency Manager or Chief Preparedness
Officer designated as lead for H1N1 preparedness
and response, fully integrated with community
emergency preparedness, public health and resource
managers
2. Seamless connectivity with local/state governmental
emergency management, public health, other
hospital Chief Preparedness Officers, and any other
support organizations
3. Emergency operations plan for H1N1
4. Surge staffing plan for the entire institution
5. Hospital Incident Command System and National
Incident Management System training, knowledge
and compliance
6. Functional Hospital Command Center
7. Training and exercise program for all involved
personnel
8. Appropriate PPE for health care staff
9. Capability to screen and test staff for illness
10. Enhanced facility security and crowd management
11. Administrative and legal support
12. Antiviral prophylaxis and vaccine availability for
staff
13. Interoperable communications system (fire, law
enforcement, EMS, emergency management,
receiving hospitals, local/regional public health,
local EOC)
14. Maintaining EMS operations during H1N1 outbreak
15. Laboratory testing protocols
16. Alternate locations and staffing for triage and
medical screening exams
17. Off-Site vaccine administration
18. Health information call centers
19. Configuration of ED waiting rooms for distancing to
the degree possible
20. Protocols for those visiting patients with fever and
respiratory symptoms
21. Environmental decontamination capability
22. Off-site mass screening capability
23. Adequate inpatient surge capacity
24. Trained and credentialed volunteers
25. Awareness of strategic national stockpile (SNS) surge
supplies and equipment and capability to receive
those supplies
26. Accurate and coordinated public information
dissemination
27. Augmented post-mortem and mortuary services
Critical Actions
Planners for surge medical response should consider the
actions in Annex 1 to achieve the necessary capabilities.
The method for performance of the actions and the
measures of performance will be determined locally. The
resulting requirements list (including those currently
present and funded, present and not funded, and not
present) will guide resource allocations and requests for
additional resources.
This plan defines roles and responsibilities that belong
to national emergency medicine organizations, such
as ACEP, and to each emergency department. It also
suggests roles and responsibilities for those with whom
interdependencies exist for surge medical response.4 It is
critical, working together locally, to define those roles,
articulate the requirements ? funded and unfunded, and to
quantify and identify the resources required to accomplish
them.
References
http://1. cdc.gov/h1n1flu/
2. http://cdc.gov/h1n1flu/qa.htm
3. Department of Health and Human Services (HHS),
Emergency Care Coordination Center (ECCC),
Centers for Disease Control and Prevention (CDC),
and Center for Medicare and Medicaid Services
(CMS); Department of Homeland Security (DHS),
Office of Health Affairs (OHA) and the Federal
Emergency Management Agency (FEMA); and the
Department of Transportation (DOT), national
Highway Traffic Safety Administration (NHTSA)
4. Responsibility for the actions in the plan are
identified as belonging to National emergency
medicine organizations, Federal government
agencies, State and Local government agencies,
State and local public health officials, emergency
departments (medical staff and administration),
and hospitals (administration, medical and nursing
staff, ancillary and support services)
[There are another 8 pages of tables]
Purpose
This plan informs health care personnel, public
health, and government officials at all levels of the
necessary capabilities that must be present for successful
emergency department management of an outbreak of
H1N1. It also enumerates the necessary actions that must
be taken to attain these capabilities. The performance
of the necessary actions will fall to parties including
professional associations, government entities at the
federal, state and local levels, public health officials
and departments at the federal state and local levels,
and hospitals ? administrators, medical staff, nursing
and support services. Those entities should undertake
the necessary operational planning to assure their
performance prior to, during and following an outbreak
of novel H1N1 influenza. The plan serves as a guide for
emergency departments to address the interdependencies
that are necessary for successful management of such an
incident. The goal of this guidance is to protect the health
care infrastructure and ensure the delivery of emergency
medical treatment during a large scale epidemic or
pandemic.
Background
Novel influenza A (H1N1) is a new flu virus that was
first detected in April, 2009. It is thought that novel
influenza A (H1N1) flu spreads in the same way that
regular seasonal influenza viruses spread; mainly through
the coughs and sneezes of people who are sick with the
virus.1
It is uncertain at this time how severe subsequent
waves of a novel H1N1 outbreak will be in terms of
illness and death compared with other influenza viruses
or the spring 2009 wave. Because this is a new virus,
most people do not have immunity to it, and illness may
be more severe and widespread as a result. In addition,
the vaccine to protect against novel H1N1 virus is not
expected to be available until after the onset of a fall 2009
wave. Therefore, health care institutions broadly, and
emergency departments specifically, should prepare for
high volumes of sick and contagious people seeking care.
Early indications are that pregnancy and other
previously recognized medical conditions that increase
the risk of influenza-related complications, like asthma
and diabetes, appear to be associated with increased risk
of complications from this novel H1N1 virus infection as
well. Adults older than 64 years appear to be at decreased
risk of contracting novel H1N1-related complications thus
far in the outbreak. Early reports indicate that no children
and few adults younger than 60 years old have existing
antibody to the novel H1N1 flu virus; however, about onethird
of adults older than 60 may have antibodies against
this virus.
So far, with novel H1N1 flu, the largest number
confirmed and probable cases have occurred in people
between the ages of 5 and 24-years-old. At this time, there
are few cases in people older than 64 years old, which
is unusual when compared with seasonal flu. However,
pregnancy and other previously recognized high-risk
medical conditions from seasonal influenza appear to be
associated with increased risk of complications from this
novel H1N1.
At the current time, CDC believes that this virus
has the same properties in terms of spread as seasonal
flu viruses. With seasonal flu, studies have shown that
people may be contagious from one day before they
develop symptoms to up to 7 days after they get sick.
Children, especially younger children, might potentially
be contagious for longer periods.2
Other pandemics in the 20th century have followed a
consistent pattern with multiple waves. If the pattern holds
true, the United States could see a second wave of the
disease in the early fall of 2009 into the winter of 2010.
The virus exhibited significant transmissibility during
the first wave of 2009. The virulence was more difficult
to estimate, because there was little disease surveillance
in effect at the point of the outbreak in Mexico; thus, the
prevalence of severe illness was unknown. As the disease
spread to the United States, the case fatality rate was very
low. After 20 weeks of the spring 2009 outbreak, there
were 11,054 confirmed and probable cases with 54 deaths.
Risk Awareness
Threat
If the virus follows the pandemic patterns of the 20th
century, health care providers should prepare for the
potential of higher level of virulence in the fall wave,
which occurred in both 1918 and 1957. Patterns would
suggest cases could appear in early fall and will be
occurring well into the normal seasonal flu months. If this
occurs, the population will not have had available vaccine,
and similar patterns of infection are expected, with higher
prevalence in children and young adults.
Should a second wave occur in the early fall, a vaccine
is unlikely to be available. Without vaccine, the best
defense the nation will have in reducing transmission
would be community mitigation strategies. Since case
rates are highest in school-aged children, school closures
would likely be one of the first strategies employed. This
would result in parents needing to remain home with
their children and the consequent loss of workplace
productivity. This would include healthcare workers,
reducing the ability of emergency departments and
hospitals to function at peak efficiency. An equally
important community mitigation strategy is keeping
people who are ill, even at the first sign, from entering
the workplace. Encouraging social distancing and
frequent hand washing policies are important parts of
the strategy. The combination of the effects of the disease
and employing these measures could affect the business
practices of all the critical infrastructure operators,
possibly impeding their ability to maintain normal
operations.
At some critical point, operations of hospitals are
affected, not only by the absence of its own workers, but
by slowdowns in transportation of supplies and support
services, the summary of which is the inability to maintain
normal operations, even for normal patient volumes.
If the novel H1N1 strain returns later than expected,
even with no difference in infection rate from the spring
2009 wave, it will strike concurrently with seasonal
influenza. In this case, the nation would face a higher
than normal influenza prevalence, higher work loss,
higher fatalities and the need for surge medical response.
In a typical seasonal flu season, 7% of adults and 30% of
children in an affected community may become infected
with flu virus, and much higher percentage in households
with a person who is ill. Each year, in the United States, on
average 36,000 people die from flu-related complications
and more than 200,000 people are hospitalized from
flu-related causes. Significant increases in those numbers
would be expected if the peak incidence of the two virus
strains overlap. If patterns of earlier pandemics hold true,
the second wave is more likely to exhibit higher virulence
? and thus higher case fatality rate. There is also no
assurance that antiviral medications will be effective for a
virus that has undergone selection pressure in the interim.
Each year, flu season can stress an emergency
department?s ability to maintain normal operations
because of the increase in both outpatient volume and
admissions. It is therefore prudent to prepare for a worse
than normal flu season. While the precise effects on
emergency departments to function cannot be predicted
with confidence, contingency plans should be made for a
challenging scenario.
Vulnerability
Population. No area of the United States would be
spared from the spread of novel H1N1. Although the
weather may affect transmission rates, no emergency
department is exempt from the risks of an outbreak.
If the transmission rates double from the spring 2009,
over 30,000 cases can be expected over the fall and early
winter. Emergency departments could see 150% of normal
volume of respiratory complaints. This may even be true in
communities where the novel H1N1 virus is not yet widely
present due to increased levels of concern by the public
regarding any respiratory related illness.
Critical Infrastructure. The ability of some critical
infrastructures to continue normal operations depends
largely on the attendance of its workforce. Others may
have plans and procedures in place for tele-work or social
distancing. The nation?s just-in-time supply chain could
experience delays in supplying goods and services, and
businesses who cannot survive operational interruptions
may expand inventories of supplies.
Hospitals are no exception to this. Pharmacies may
not be able to get additional supplies from distributors
or sources higher in the chain, domestic and foreign.
Supplies of personal protective equipment ( PPE) and
other supplies may require stockpiling, and food services
could encounter supply problems due to production and
delivery. The workforce may be depleted due to infection,
fears of coming to work in an infectious environment, or
the need to care for children out of school or other family
members. Medical care is highly labor intensive; thus,
service delivery is expected to be exquisitely sensitive to
the ratio of service demand to workforce supply.
Consequence. The consequences to society will
vary with the severity of the illness (transmission and
virulence), the degree to which the population is prepared
and resilient (vaccinated, compliant with community
mitigation strategies, and educated about the threat), and
whether business and industry can sustain productivity
during a pandemic. An outbreak with the severity of
the 1918 pandemic can be a nation-changing event with
massive mortality in young people who are economically
responsible for young families and, in large part, for our
nation?s defense.
Lesser-severity outbreaks can result in temporary
disruptions in the flow of goods and services, and would
likely cause further stresses on an over-burdened health
care system. Certain medical services would be delayed or
unavailable, potentially causing secondary morbidity and
mortality to those unaffected by influenza.
A mild outbreak or no change from baseline
seasonal influenza will undoubtedly result in charges
of over-reaction and fear mongering, which could have
detrimental effects on future compliance with public
health measures, future influenza immunization initiatives
and compliance with a response to public health
emergencies.
There are consequences to planning, including financial
investment and diversion of human resources, and
consequences to the lack of planning should the threat
become reality. In either case, a prudent assessment of risk
is vital and prudent planning in response to that risk is
necessary to avoid victimization.
Response to the Threat
The American College of Emergency Physicians
(ACEP) supports comprehensive response planning by
its members and their institutions. ACEP will work with
its corresponding professional associations (e.g. nurses,
prehospital professional, EMS medical directors, hospitals,
public health associations) to implement the actions and
satisfy the requirements of the planning process. ACEP
will seek support as necessary on behalf of its members
from federal government entities responsible for surge
medical response capabilities.3 ACEP state chapters
should seek the involvement of their state health directors.
Members should involve local emergency managers,
political leaders and local health directors.
The national strategic plan planning process and
the capabilities and actions herein should prompt a
local process that defines how to operationalize these
capabilities and to articulate the necessary requirements
to perform them. Those requirements should result in
the targeting of resources and the identification of gaps
that may exist in funding. Those unfunded requirements
must be communicated to local emergency managers and
political leaders to guide resource allocations and possible
supplementary grant funding from federal entities.
Emergency physicians and their professional colleagues
in nursing and prehospital care will be on the front line
of any emergency requiring surge medical response
capability. They will be the ones to answer the challenge
of waves of patients presenting for care. They will also be
the beneficiaries of good planning or the victims of the
lack of it. ACEP will exercise all of its influence to ensure
that patients can be cared for and that its members are
sufficiently resourced, trained, equipped and exercised to
fulfill their critical mission.
Triggers for various parts of a response plan are part
of the planning process, and the authorities to take
action must be clear. Likely, as cases are recognized and
increasing strain is put on acute care facilities, the health
care professionals and administrators in those facilities
will be the first to know there is a crisis. Communications
with local and state public health directors for
situational awareness is of paramount importance.
Clear communications protocols must be created and
exercised on a regular basis prior to an event. Agreements
on stepwise implementation of the relevant parts of the
plan must be in place to avoid disruptions in services
during the ramp-up phase and to allow for the necessary
provision of resources.
Just as the parts of the plan will be implemented with
the situational awareness of the local leaders and public
health officials, so will ?standing down? of the pandemic
plan. Agreements must be in place as to the triggers for
the authorities to return to the prior steady state. This
decision must be made with situational awareness of the
epidemiology of the disease in the community and cannot
be done, institutionally, in a vacuum.
Depending on the severity of the pandemic and its
virulence, institutions may face a depleted workforce.
In addition to those lost to illness, there may be those
with concerns about being in an environment of higher
risk from exposure to infectious disease. There may be
personnel who have temporary reasons for not returning
to the workplace, such as pregnancy or needing to care for
family who remain ill.
ACEP will work with its counterpart professional
associations and the federal government to dispense
actionable information to its members so that they remain
aware of current information on the changing situation
and can make decisions accordingly.
Management Strategy
ACEP will use all means necessary to (1) ensure that
our patients receive the best care possible, and (2) ensure
that its members are able to fulfill their professional
responsibilities. The National Strategic Plan for Emergency
Department Management of Outbreaks of Novel H1N1
Influenza follows the federal template for management
of biological threats, as outlined in Homeland Security
Presidential Directive #10. The pillars of that strategy are:
Threat Awareness, Protection and Prevention, Surveillance
and Detection, and Response and Recovery.
This National Strategic Plan for ED Management of
H1N1 outbreaks adapts this template to form its own
pillars of prescribed capabilities:
? Situational awareness
? Protection of the emergency department
infrastructure and personnel
? Prevention of disruptions in service delivery
? Organized, timely surge medical response
? Recovery to the previous steady state
Scenario
[This scenario is a notional planning scenario based on
available information, within which are certain assumptions
that may change as information becomes more precise. It is
meant to be challenging and realistic, but is not predictive.]
The first cases of novel H1N1 reappear in an
unspecified area of the nation in late September. Early
cases are not recognized as influenza, and will be treated
conservatively, affording the opportunity for transmission
to schoolmates and family.
The vaccine for the novel H1N1 will not be ready for
distribution in large volumes until late October. Vaccine
for the novel H1N1 may require two injections, at least two
weeks apart, to stimulate immunity. Immunity will not
be sufficient to protect subjects from infection until two
weeks after the second injection.
Local officials will be hesitant to implement community
mitigation strategies early in an outbreak, especially school
closure so close to the beginning of the school year. The
media will continue to fuel the public sentiment that
health officials over-reacted to the spring wave and are
doing likewise to the fall cases. There will be political
pressure to keep schools open because of large numbers
of workers without ?time off? benefits to care for their
children. The Federal government will not have solutions
in place, such as emergency wage replacement, to mitigate
that pressure. Because of economic pressures and high
value placed on jobs in a weakened economy, workers will
continue to work when sick, exacerbating transmission in
the most contagious stage of their illness.
After a few weeks of the fall wave, the prevalence
in affected parts of the country will increase. The first
few deaths will be reported, some in young individuals.
Emergency departments will begin to see large volumes of
people who are not ill with the flu but are concerned that
they or their children ?might have it.? They are requesting
screening and prescriptions for antivirals. Emergency
departments will experience a 150% increase in chief
complaints with respiratory symptoms.
By mid-October, 15,000 cases will be reported across
the country, with hot spots in urban areas that have not
employed community mitigation strategies. The highest
prevalence will be among children and young adults,
but during this wave, there will be a 5-fold increase in
mortality, with 250 deaths by late-October, mostly in
school-age children and those in late teens.
The CDC will document the increased virulence, and
communities will begin to close schools. Health guidance
will be provided encouraging those with fever, cold
symptoms, sore throat or respiratory symptoms to remain
at home and wear masks in public, and to go to their
doctor or the emergency department if acutely ill. This
will be concurrent with fall allergy season, when a large
proportion of people report nasal symptoms in a normal
year, and many of those will normally have sore throat
and cough. The highest concentration of people who have
no doctor or health coverage is the same population at
greatest risk for becoming ill with novel H1N1: children
and young adults.
Even though the prevalence of illness is less than 2%,
some public officials may discourage the use of public
transportation or participating in other close gatherings.
There will be increased demand on emergency medical
services for transport of patients to the hospital who would
normally see a doctor via public transportation.
As the prevalence of disease increases, deaths of
children will be in the news regardless of the case fatality
rate, and concerned parents will want their children
checked if they have any related symptoms. Primary
care providers who may have the capacity to see only a
few extra people per day, will be overbooked and will be
referring patients to the emergency department.
Planning Assumptions
1. The behavior of the virus is not predictable but is
likely to return in the fall of 2009 and persist into
2010, complicating usual seasonal flu management.
2. The fall 2009 wave will follow the pattern of
pandemics of the 20th century by having greater
virulence than the initial wave.
3. Children and young adults will experience the
highest attack rates.
4. Adults over 65 will have lower attack rates due to
previous influenza exposures.
5. The onset of the fall wave will not be detected until
after it has begun.
6. A well-matched vaccine will not be available until
mid-October 2009 at the earliest and will not be
effective until weeks after the final doses.
7. Community mitigation measures can be effective to
slow disease transmission and will be the only tool
available for prevention.
8. Mass anti-viral chemoprophylaxis will not be
recommended.
9. Continuing sensitivity of H1N1 to antiviral
medications is unknown.
10. Emergency medical and hospital planning for an
H1N1 pandemic will be successful only if it is
interoperable with emergency management and
public health.
Capabilities for Emergency Department Response
to a Severe H1N1 Outbreak
1. Trained Emergency Manager or Chief Preparedness
Officer designated as lead for H1N1 preparedness
and response, fully integrated with community
emergency preparedness, public health and resource
managers
2. Seamless connectivity with local/state governmental
emergency management, public health, other
hospital Chief Preparedness Officers, and any other
support organizations
3. Emergency operations plan for H1N1
4. Surge staffing plan for the entire institution
5. Hospital Incident Command System and National
Incident Management System training, knowledge
and compliance
6. Functional Hospital Command Center
7. Training and exercise program for all involved
personnel
8. Appropriate PPE for health care staff
9. Capability to screen and test staff for illness
10. Enhanced facility security and crowd management
11. Administrative and legal support
12. Antiviral prophylaxis and vaccine availability for
staff
13. Interoperable communications system (fire, law
enforcement, EMS, emergency management,
receiving hospitals, local/regional public health,
local EOC)
14. Maintaining EMS operations during H1N1 outbreak
15. Laboratory testing protocols
16. Alternate locations and staffing for triage and
medical screening exams
17. Off-Site vaccine administration
18. Health information call centers
19. Configuration of ED waiting rooms for distancing to
the degree possible
20. Protocols for those visiting patients with fever and
respiratory symptoms
21. Environmental decontamination capability
22. Off-site mass screening capability
23. Adequate inpatient surge capacity
24. Trained and credentialed volunteers
25. Awareness of strategic national stockpile (SNS) surge
supplies and equipment and capability to receive
those supplies
26. Accurate and coordinated public information
dissemination
27. Augmented post-mortem and mortuary services
Critical Actions
Planners for surge medical response should consider the
actions in Annex 1 to achieve the necessary capabilities.
The method for performance of the actions and the
measures of performance will be determined locally. The
resulting requirements list (including those currently
present and funded, present and not funded, and not
present) will guide resource allocations and requests for
additional resources.
This plan defines roles and responsibilities that belong
to national emergency medicine organizations, such
as ACEP, and to each emergency department. It also
suggests roles and responsibilities for those with whom
interdependencies exist for surge medical response.4 It is
critical, working together locally, to define those roles,
articulate the requirements ? funded and unfunded, and to
quantify and identify the resources required to accomplish
them.
References
http://1. cdc.gov/h1n1flu/
2. http://cdc.gov/h1n1flu/qa.htm
3. Department of Health and Human Services (HHS),
Emergency Care Coordination Center (ECCC),
Centers for Disease Control and Prevention (CDC),
and Center for Medicare and Medicaid Services
(CMS); Department of Homeland Security (DHS),
Office of Health Affairs (OHA) and the Federal
Emergency Management Agency (FEMA); and the
Department of Transportation (DOT), national
Highway Traffic Safety Administration (NHTSA)
4. Responsibility for the actions in the plan are
identified as belonging to National emergency
medicine organizations, Federal government
agencies, State and Local government agencies,
State and local public health officials, emergency
departments (medical staff and administration),
and hospitals (administration, medical and nursing
staff, ancillary and support services)
[There are another 8 pages of tables]
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