Complacency could be deadly in pandemic

Hospitals are ill-prepared, reports say

Hospitals are ill-prepared to cope with even a mild pandemic and are likely to face shortages of staff, protective equipment, bed space, and other supplies.1

The pressures that face hospitals daily would be magnified and health care systems would quickly become overwhelmed if there were a sudden influx of patients suffering from a novel influenza virus, according to a panel of preparedness and public health experts and hospital leaders convened by the Center for Biosecurity of the University of Pittsburgh Medical Center.

That conclusion echoes other warnings. Complacency could be deadly, says William Charney, DOH, a national occupational health consultant based in Seattle who compiled the recent book, Emerging Infectious Diseases and the Threat to Occupational Health in the U.S. and Canada (CRC Press, 2006).

"We are taking for granted that our health care systems are going to be able to deal with thousands of sick and dying people, when in fact at the current level of preparedness they will be overwhelmed and chaos is quite predictable," Charney writes.

About half of the nation's emergency departments (48%) function at or above capacity, according to the Center for Biosecurity report. About 30% of hospitals lose money, and the total number of hospital beds, hospitals, and emergency rooms has been declining.

"We have a lot less surge capacity in our health care system now than we did even 20 or 30 years ago," says Eric Toner, MD, senior associate with the Center for Biosecurity and lead author of the report.

The pandemic of 1968 was one of the mildest on record. But Toner says, "I doubt we could handle a 1968 pandemic now. Our hospitals have trouble dealing with a bad flu season as it is."

One of the greatest areas of weakness involves the protection of the health care workforce. Hospitals already struggle with staff shortages, particularly with respect to nurses or other licensed practitioners. Yet more than a third of hospital employees may fail to show up if there is a pandemic; in one survey, 42% of health care workers said they would not report to work during a flu pandemic.2

"The already existing shortage of health care workers will certainly be worse in a pandemic," says Toner. "How bad it will be is anybody's guess, but certainly it will be significant."

Even now, hospitals are competing with corporations and governments for a limited supply of respirators, and some are having trouble getting the respirators to meet their current needs, such as protection against tuberculosis.

Rural hospitals, with limited local resources, face particular difficulties preparing for a pandemic. "Every hospital in every community needs to be working in collaboration with its neighbors and [local] emergency management organization to plan cooperatively," says Toner.

For rural hospitals, that may mean reaching out to other health care facilities that are miles away, Toner says.

Preparing for a pandemic will be costly; the Center for Biosecurity estimates that to be ready for a severe pandemic, similar to the historic influenza pandemic of 1918, an average-sized hospital of 164 beds would need to spend $1 million, including $200,000 to develop a pandemic-specific plan, $160,000 for staff education and training, $400,000 to stockpile "minimal" personal protective equipment, and $240,000 to stockpile basic supplies.

Hospitals also will need to spend about $200,000 a year to maintain preparedness, the center estimates.

Meanwhile, a pandemic would financially cripple hospitals, as they would lose money on delayed or canceled elective procedures while paying more for staff and supplies and treating more uninsured patients.

The solution: more government spending for preparedness, tied to specific goals, and funds to reimburse hospitals for uncompensated care and extraordinary costs in a pandemic, the center said.

But don't rely on the federal government to save the day when a pandemic hits. Although there is a national stockpile of antiviral medications, N95 respirators, and vaccine, the supply is small compared to the immediate demand that would occur. Preparation must be local and regional, says Toner.

Yet for most hospitals, pandemic planning has been sketchy. "Hospitals are not taking this nearly as seriously as they should," says Toner. "Few hospitals have started stockpiling [PPE, antivirals, and other supplies] to the extent that they should. Almost every hospital has some sort of pandemic plan, but they've not been committing the resources necessary to get prepared."

Without HCWs, all is 'moot'

Occupational health is one of the most critical areas of preparedness. "The No. 1 priority is protecting the health care workers. If we don't have health care workers, then everything else is moot," says Toner.

Yet Charney worries that hospitals are not planning to provide adequate respiratory protection. Charney and contributors to his book, Mark Nicas, John H. Lange, and Giuseppe Mastrangelo, contend that health care workers caring for patients with emerging infectious diseases need respirators that are more protective than the N95 — either the elastomeric half-mask respirator or powered air-purifying respirator (PAPR).

Both of those respirator types are reusable; the PAPR does not require fit testing. Currently, the Centers for Disease Control and Prevention says that the use of an N95 during an influenza pandemic would be "prudent" and that an N95 or greater respiratory protection should be used during aerosolizing procedures, such as a bronchoscopy.

"We don't know how many viruses will be emitted and how far they'll travel and what the dose response will be [with an emerging infectious disease]," Charney asserts. "While the experts are arguing about [how influenza is transmitted], they're recommending lower-quality safety measures."

In their planning, hospitals must think through issues of supply for disposable products and disinfection of reusable ones. Toner recommends tiered levels of protection based on the health care worker's patient contact and degree of risk.

"Hospitals can't just stockpile one [item]," he says. "They need to really think this through and stockpile a number of different measures."

Cohorting patients can reduce the potential employee exposure and allow the hospital to concentrate its protective measures on those employees at greatest risk, he notes.

Lining up volunteers

If your health care workers don't feel safe, they won't show up for work. That is a maxim that many occupational health experts emphasize in pandemic planning.

HCWs also may stay home to care for ill family members or as the only caregiver for children whose schools have been closed as an infection control measure. Meanwhile, you'll need more health care workers than ever to care for a surge of patients.

As part of pandemic planning, hospitals need to identify volunteers, including retired health care workers and those who have left clinical care, who can help during a crisis period, according to the Center for Biosecurity. Their credentials would need to be verified, and the registration of volunteers would need to be kept up to date.

The U.S. Department of Health and Human Services is developing a state-based Emergency System for Advanced Registration of Volunteer Health Professionals. Hospitals should contact their state public health departments for more information on those efforts.

Meanwhile, hospitals should plan for just-in-time training for volunteer workers and employees who may take on new duties when elective procedures are cancelled.

"What are the essential things they need to be taught in order to do what we ask them to do?" says Toner. You should also consider "what functions in a hospital can be done by relatively untrained people."

References

  1. Toner E, Waldhorn R, Maldin B, et al. Meeting report: Hospital preparedness for pandemic influenza. Biosecurity and bioterrorism: Biodefense strategy, practice, and science. 2006.;4:1-11. Available at www.biosecurityjournal.com/TONER.pdf.
  2. Balicer RD, Omer SB, Barnett DJ, et al. Local public health workers' perceptions toward responding to an influenza pandemic. BMC Public Health 2006;6:99.