H1N1 could overwhelm U.S. in the next two months

[Chuck]

http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/sep0909ers.html


ER physicians fear possible fall flood of flu

Maryn McKenna * Contributing Writer

Sep 9, 2009 (CIDRAP News) ? As children return to school and promptly become infected with H1N1 influenza, emergency-room (ER) physicians nationwide are becoming increasingly anxious over their ERs' capacity to deal with an influx of flu patients.

Many of the physicians work in emergency departments that experienced a spring onslaught of flu and fever cases when H1N1 first struck. In some cities, those cases were part of an early wave that receded; in others, the count of flu cases climbed and has kept climbing through summer months that usually are flu-free.

In either situation, the physicians say they are concerned that the expected fall increase in H1N1 flu?plus the annual arrival of seasonal flu?will significantly perturb a system that has little capacity to handle excess demand. And if H1N1 flu undergoes enough mutation or reassortment to add significant virulence to its notable contagiousness, they add, chaos could result.

Potential for a perfect storm
"From what I have been reading, the flu season in the Southern Hemisphere has been very, very bad?they have been swamped with an increasing number of cases," said Dr. Stuart Bradin, an assistant professor of pediatrics and emergency medicine in the

University of Michigan Health System. "So I think we are in quite a bit of danger of having a very bad flu season here. Having seasonal flu on top of that, and considering that the pandemic flu strain may become more virulent than its initial presentation, I think is the potential for a perfect storm."

Some physicians have been hearing early rumbles of that storm since H1N1 appeared in late April.

"The months of May, June, and July were 3 of our top 6 months ever, in terms of emergency department volume, going back at least 10 years," said Dr. Brian Zink, chair of emergency medicine at Warren Alpert Medical School at Brown University in Rhode Island.

Dr. David Munter, emergency department director at Sentara Obici Hospital in Suffolk, Va., said: "I have never before, in a 28-year career, seen flu in June, July, and August, but we had it, and it was all in teens and young adults. We had no summer dip [in cases] at all."

He added: "I think when school starts, it will explode."

The physicians say that many of the flu patients they saw and expect to see are not gravely ill. Some, especially in the spring, were worried well seeking tests or reassurance. Most who came for care over the summer had fever and other flu-like symptoms, but did not need to be admitted to the hospital and were discharged to recover at home.

The spring wave of cases "increased our wait times and reduced efficiencies," Zink said. "Individuals who needed to be wearing masks, we had to stop and get masked in triage, so it slowed the triage process down. And we went into rooms masked and using contact precautions, which adds a little bit of time to each encounter. But we see 100,000 patients a year in our main hospital [ER], so if you add even a few minutes to each patient, it slows everything down."

ERs already under stress
H1N1 arrives at a time when emergency medicine nationwide is widely considered "at the breaking point"?the title of a 2006 Institute of Medicine report on the precarious state of emergency care. That report estimated that ER visits rose by 26% between 1992 and 2003, from 89.8 million to 114 million in a year, while 425 emergency departments and 703 hospitals closed and the number of hospital beds in use shrank by 198,000.

In April of this year, the American Hospital Association updated that calculation in a report that found 50% of 1,078 hospitals were treating more uninsured patients in their ERs, while approximately 10 hospitals per month were laying off 50 staff or more.

Meanwhile, the President's Council of Advisors on Science and Technology estimated in August that H1N1 flu may infect 30% to 50% of the U.S. population this coming winter, leading to as many as 1.8 million hospital admissions that could include 300,000 patients requiring placement in an intensive care unit (ICU). From 30,000 to 90,000 Americans could die, the report said, up to three times as many as die from flu in a normal year.

H1N1's progress through the Southern Hemisphere flu season appears to prefigure that. Last week, Dr. Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), acknowledged that Southern Hemisphere hospitals "had challenges to keep up with the number of people coming in" even though there was "no increase in the level of severity, no increase in the death rate."

Medicine's concern for H1N1's potential impact on ERs is so acute that the American College of Emergency Physicians, emergency medicine's specialty society, in July issued a "National Strategic Plan for Emergency Department Management and Outbreaks of Novel H1N1 Influenza." The plan, written under contract to the Department of Health and Human Services, walks ER directors through a potential H1N1 scenario, lists vulnerabilities that may prove to be weak points, and compiles 27 essential capabilities that ERs must fulfill to handle significant new demand.

Physicians preparing for the fall say uncertainty is a key element in their anxiety. On one hand, H1N1 flu and seasonal flu could cause mostly minor illnesses?but if those mildly ill patients come to ERs, they will take time to interview, assess, and treat, and take staff attention and bed space that might otherwise be devoted to the seriously ill.

That is likely to increase ERs' "length of stay," one key measure of how smoothly an emergency department is functioning. And while they are there, those patients may pose an infection risk to any other patients around them, who may be chronically ill or suffering from any of the underlying conditions that have been implicated in H1N1 deaths to date.

If on the other hand the two flus begin to cause very serious illnesses, they could significantly increase hospital and especially ICU admissions. Such patients might bypass an emergency department or stop in it only briefly, but they could nevertheless have a profound effect on its operations. That is because "boarding," or holding admitted patients in an ER until a bed opens up elsewhere in the hospital?another key measure of ER quality?is created when ICU and ward beds are full.

In a 2006 analysis, the Center for Biosecurity at the University of Pittsburgh Medical Center estimated that responding to a severe pandemic would require 4.6 times as many ICU beds and twice as many hospital beds as exist in the United States.

Strategies for preventing overload
Around the country, emergency departments and the hospitals that house them are crafting solutions that they hope will head off an ER overload. Many are considering creating satellite triage stations located away from ERs?in hospital parking lots, repurposed clinics, or even drive-throughs?all of which rely on keeping flu patients out of the ER and bringing healthcare personnel out to meet them.

Children's Healthcare of Atlanta, which operates three hospitals, recently placed on its website an interactive decision tool that allows parents to assess the severity of a child's symptoms so that only children who need emergency care will be brought to its ERs.

In Virginia, Munter envisions physically dividing his hospital's waiting room into two zones; one, a flu zone, would feed into a pre-designated isolation area within the ER. And the quality-focused Institute for Healthcare Improvement (IHI) will shortly publish a monograph proposing that flu patients be separated more radically, by being steered into what physicians call a "pathway"?a multi-step protocol triggered by a particular set of signs and symptoms?that would not only put them in certain rooms but process them at different speeds depending on results of tests given in a particular rapid order.

Several emergency physicians said that what they fear most for the fall and winter is not an onslaught of flu, but a slow crawl up the epidemic curve. An onslaught, they argued, would be recognized as a crisis and would trigger a coordinated response in the same way a plane crash does. But a steady increase, though it might eventually reach disastrous proportions, would be perceived at any moment as ER business as usual: vastly overcrowded but not deserving outside response.

"Our fear is that it will hit hard enough to really disrupt emergency department operations, but not hard enough to engage crisis-management protocols," said Dr. Joseph "Jody" Crane, a co-author on the forthcoming IHI paper and business director of the Fredericksburg (Md.) Emergency Medical Alliance. "That could wreak havoc on the running of emergency departments."

See also:

2006 Institute of Medicine report: "Hospital-Based Emergency Care: at the Breaking Point"
http://www.iom.edu/CMS/3809/16107/35007.aspx

2009 American Hospital Association report "The Economic Crisis: The Toll on the Patients and Communities Hospitals Serve"
http://www.aha.org/aha/content/2009/pdf/090427econcrisisreport.pdf

American College of Emergency Physicians' "National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza"
http://www.acep.org/WorkArea/DownloadAsset.aspx?id=45781

Toner E, Waldhorn R, Maldin B, et al. Hospital preparedness for pandemic influenza. (Meeting Report) Biosecur Bioterror 2006;4(2):1?11 [Full text]

Childrens' Healthcare of Atlanta Interactive Flu Assessment Tool

 

[Treyfish]

H1N1 could overwhelm U.S. in the next two months

http://www.flutrackers.com/standard/display/project_display.php?proj_identifier=2009/08/28/h1n1-flu

<!-- H1N1 Flu

-->

Minnesota Public Radio
September 10, 2009


Minneapolis ? Pandemic influenza could overwhelm the nation's health care system, schools and businesses as early as October, according to participants in a University of Minnesota panel discussion today on the new H1N1 virus.
Michael Osterholm directs the Center for Infectious Disease Research and Policy. He told the U of M audience that based on how easily the flu virus is transmitting from person to person, he thinks it's possible many people will be infected before a vaccine is available.
"This is going to build around the country over the next three to four weeks, and we're going to see more and more of the infection spread out of the college campuses, out of the high schools, out of the schools, out of the daycares,," said Osterholm. "It's going to basically be in the working class population of 20 to 55-year-olds, and it's going to be an interesting situation."
Osterholm added that some U.S. hospitals are already being overwhelmed with pandemic flu cases. He said emergency rooms in Atlanta are recording the highest numbers of pediatric patients they've ever had with influenza-like illnesses.
Osterholm said the flu swamped the health care system in the southern hemisphere, where the flu season just ended, and caused other major disruptions.
"Absenteeism at work was at record levels, including that of universities where they actually had to close schools in the southern hemisphere -- not out of the fear of contagion as such. They didn't have enough teachers to run the schools," said Osterholm.
In the northern hemisphere, Osterholm said some companies in India and China are reporting absentee rates as high as 30 percent due to influenza.
The head of the World Health Organization recently said the new strain of pandemic flu spreads four times faster than other viruses.
So far most of the illnesses associated with the virus have been considered mild. But 40 percent of the deaths worldwide have been in young people who were otherwise healthy.:tiphat:http://minnesota.publicradio.org/display/web/2009/09/10/flu-update/?refid=0

 

[Tonka]

Disaster Plans Being Revised For Swine Flu

Disaster Plans Being Revised For Swine Flu

http://www.washingtonpost.com/wp-dyn/content/article/2009/09/12/AR2009091200936.html

Disaster Plans Being Revised For Swine Flu
Strains on Emergency System Feared


By Rob Stein
Washington Post Staff Writer
Sunday, September 13, 2009


Disaster Plans Being Revised For Swine Flu
Special Report: Swine Flu
As the second wave of H1N1 infections begins in the United States, scenes like this from the command center of the Maryland Institute for Emergency Medical Services Systems have federal, state and local health authorities nationwide scrambling. Even if swine flu remains a mild infection, the pandemic could be the tipping point for an emergency medical system teetering on the edge.

"The worry is, the health-care delivery system could be overwhelmed by people who are sick or think they are sick," said Kim Elliott of Trust for America's Health, a nonpartisan think tank and advocacy group.

In response, officials across the country are rewriting disaster plans and stocking up on masks, gowns, drugs and other supplies -- and inventing new strategies. One key line of attack will be encouraging people who are not really sick or are suffering only mild symptoms to recover at home. And in a move creating intense debate, experts are searching for ways to help health-care providers quickly screen those who do seek help and separate bad cases from less-severe ones.


The swine flu virus, also known as H1N1, could infect up to half the U.S. population, making as many as 1.8 million sick enough to need hospitalization, including as many as 300,000 who might need intensive care, according to a presidential advisory council estimate. Even though scientists reported Thursday that the vaccine appears to work much better than hoped, the second wave of U.S. infections is expected to peak next month -- well before the shots become widely available.

"There will be millions and millions of people seeking care in a relatively short period of time," said Eric Toner of the University of Pittsburgh's Center for Biosecurity, noting that the nation has only about 85,000 critical-care beds. "Only a small percentage of those people will require hospitalization and a small percentage will require intensive care. But it's still an awful lot of people."

The federal government is sending $350 million to state and local governments, including $90 million to help the nation's 4,897 hospitals and 3,829 emergency rooms prepare. In addition, the Strategic National Stockpile has more than 116 million masks, more than 52 million doses of antiviral drugs and 4,500 ventilators.

Federal officials are asking hospitals to report more current details about how stressed or well-equipped they are so the officials can help coordinate care in a crisis. They have also begun to count available ventilators, which could be crucial in caring for the sickest patients.

After the virus emerged in Mexico this spring and spread to the United States, many hospitals experienced a surge in patients, and some emergency rooms in New York City and elsewhere were overwhelmed. Experts say they expect the virus to linger longer this fall and winter, raising deep concern about whether the stockpiles of supplies, the contingency plans to improvise extra beds and backup plans to call up reserves of doctors, nurses and other health-care workers will be sufficient.

The first line of defense will be to persuade those with mild symptoms to stay home to minimize the spread of the virus and to make sure those who really need care receive it, while still providing treatment for the usual number of heart attack, gunshot and accident victims.

Federal, state and local health officials are planning multimedia campaigns -- including radio and television ads, subway signs, refrigerator magnets and Twitter feeds -- to convince Americans that they do not need to run to a doctor or emergency room at the first sign of cough or fever.

Many states and some cities are creating Web sites and hotlines for people to get information and, in some cases, talk to a nurse to find out what kind of care they need.

The second line of defense will be procedures to enable doctor's offices, clinics and public health centers to help as many patients as quickly as possible.

"What you do is identify patients who are at high risk and do a very focused set of questions that includes things like: 'Are you dehydrated? Are you short of breath?' It's very much a large-scale screening, like a mass vaccination in the schools where you line them up and keep them moving," said James M. Chamberlain of the Children's National Medical Center in Washington.

Chamberlain acknowledged that, although necessary, such procedures have risks: "We're going to be seeing thousands of children who are well, who are doing fine. I don't want to miss the one in a thousand who isn't doing fine. That's always the concern: missing the one sick kid who isn't doing well."

However, the nation's emergency physicians warn that such steps will be inadequate, calling it "imperative" that the Obama administration do more.

The American College of Emergency Physicians is urging the Department of Health and Human Services to endorse a nationwide protocol to help the public decide when to go to an emergency room, see a doctor within 48 hours or stay home. A national diagnostic standard, automated for use via the Internet or telephone call centers, could dramatically reduce unnecessary visits, officials said.

"It was not an easy thing for emergency physicians -- whose culture is, 'We are ready for everything; we can handle anything, anytime' -- to say that we as a group have to make a statement about people not coming to our emergency departments," said Lynne D. Richardson, chairman of ACEP's public health committee. "But it's clear to us we have to do that."

Some federal officials, however, worry about missing people who later become sick and die, creating liability risks. A government-endorsed triage tool could also appear to limit access to emergency care as Congress debates health-care reform.

"This is occurring in, I think, a highly charged environment where people are very concerned right now about denial of access to health care," said Jesse Goodman, chief scientist and deputy commissioner of the Food and Drug Administration, at an Institute of Medicine forum. "We have to do the right thing from the public health point of view, but we also have to consider this in the lens it's going to be viewed in."

In the meantime, many doctor's offices are planning to take steps on their own.

"We're going to be the ground zero of this thing," said Ted Epperly, president of the American Academy of Family Physicians, who runs a large family-medicine practice in Boise, Idaho. His office plans to bring in extra nurses to help diagnose conditions over the phone; put masks on suspected H1N1 patients as soon as they walk into the office and separate them from others; and give exposed workers antiviral drugs to protect them from becoming infected.

Large numbers of health-care workers getting sick would cripple the system. So hospitals, doctor's offices and other medical facilities are stocking up on antiviral drugs, masks and gowns, and are urging employees to get vaccinated against the regular seasonal flu as well as H1N1.

Facilities are also updating contingency plans developed over the past few years to deal with the much more deadly avian flu. Public health departments and hospitals could open flu clinics to divert patients from emergency rooms for treatment.

"Maybe the plan three years ago assumed people would use an abandoned shopping mall. But maybe that mall has been demolished or is back being a mall again and isn't available anymore," said Dora Anne Mills, Maine's public health director. "Or maybe now that it's more younger people being affected, it would be better to use a local college gym so we can be in a part of town where more patients are located."

In a worst-case scenario, some states, such as Iowa and California, have mobile hospitals consisting of a series of connected tents that they could rush to any area and erect, for example, on a football field.

Hospitals also have contingency plans that would enable them to convert other parts of their facilities into intensive care units. The Children's National Medical Center, for example, can convert any room in its new East Wing for critical care.

If hospitals are short of staff or overwhelmed with flu patients, they could also discharge other patients early and postpone non-emergency care, such as elective surgery.

Because H1N1 disproportionately affects children, many experts worry about the system's ability to handle a large number of pediatric patients. Many facilities do not typically stock medical equipment such as breathing tubes and intravenous tubes for children.

"Kids come in all shapes and sizes," said Joseph L. Wright of the American Academy of Pediatrics. "What could be real disaster is if you don't have equipment to fit the kid in front of you."

Staff writer Spencer S. Hsu contributed to this report.