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EDs not taking chances with H1N1, protocols updated, supplies checked
Departments taking a 'better-safe-than-sorry' approach
Even with the outbreak of H1N1 influenza in its relative infancy, and no one knowing for certain how dire the situation might become, ED managers and their staffs are taking the situation very seriously. If we are fortunate, and this particular chapter ends with a whimper, then their actions still will be a good test of how well prepared they are for a pandemic.
Precisely because this is an entirely new strain, experts can't predict with certainty what will happen. Even if this current outbreak ends with the heat of summer, there are no guarantees the virus will not return when the flu season begins next fall.
"The big concern is that this is a new and unknown virus that no one has been exposed to before, and it seems to have spread rather quickly," says Charles Pattavina, MD, FACEP, chief of emergency medicine at St. Joseph Hospital in Bangor, ME.
David Ross, DO, FACEP, an emergency physician at Penrose Hospital in Colorado Springs, CO, and a spokesman for the American College of Emergency Physicians (ACEP), says, "The severity of these cases in the U.S. so far has been very mild, so the quick answer is it's not very serious. But the potential for spread is much more serious and more concerning and, in the fall, this virus may mutate and become substantially more severe."
Katherine West, BSN, MSED, CIC, infection control consultant at Infection Control/Emerging Concepts in Manassas, VA, says, "We just don't know how serious a threat this is, but so far it seems to be acting as a normal flu would. We have to keep this in perspective." That "perspective" includes the fact that about 36,000 people in the United States die from influenza every year, she says. "Yes, there are going to be deaths, but the media is inciting fear in the way they cover this," West complains. As ED Management goes to press, the total number of confirmed cases in the United States is nearly 900, including two deaths.
Nonetheless, ED managers, including Pattavina, are taking no chances. "We've made sure that we're up to date on fitting for [N95] masks, and we've reviewed the usual procedures for precautions with respiratory illnesses," he says. At the state's request, his department has changed the swab it uses for flu testing so that the same swab also can be used to test for H1N1, Pattavina says. "They've asked us the call them if we want to test for swine flu, to make sure the case meets their criteria, such as travel history, exposure to someone who has or is suspicious for the disease, and if they have gastro symptoms, which do not typically accompany the flu," he says.
Finally, Pattavina adds, his department has cut back on "liberal" flu testing so as not to run out of supplies.
At Penrose hospital, Ross has a built-in advantage. "We have a physician on our emergency medicine staff that has an MPH, and he's very interested in pandemics and influenza, so in addition to all the outside sources we get information from, like the [Centers for Disease Control and Prevention] and the Department of Public Health, he's been giving us advice as well," he says.
So, for example, this doctor has recommended that additional questions be asked during triage to determine if the patients are at risk for H1N1, such as whether they have fever, cough, congestion, vomiting, and diarrhea. "If they answer 'yes,' we ask if they have been in Mexico or any of the border states," Ross says. "If they answer 'yes' again, we put them in a surgical mask and in a room with a door instead of a bay." Then, he says, the doctors or other staff members treating them wear N95 masks. "After the physician asks some more in-depth questions, the decision is made whether to keep the masks on or remove them," Ross adds.
EMS chief beefs up monitoring
Don't take any chances with H1N1. Just ask Mike McEvoy, PhD, REMT-P, RN, CCRN, EMS coordinator, Saratoga County, NY, EMS director, New York State Association of Fire Chiefs, and clinical associate professor, critical care medicine, at Albany (NY) Medical College.
"We've beefed up monitoring; at our dispatch center, we've activated a protocol called Severe Respiratory Illness, which adds extra questions onto the information collected from callers," says McEvoy, who works in the critical care unit at Albany Medical Center. For example, he says, callers are asked if they've been to Mexico or been around somebody who has been there in the last seven days, if they have a fever over 101°, and if they have a cough or any symptom of respiratory illness. "The protocol requires that dispatch conveys that information to the fire department and EMS people who respond," McEvoy explains.
In addition, he has contacted all chief officers on fire departments and at EMS sites and told them to review plans for pandemic flu and "make sure they're ready to go in case of a huge outbreak."
When to put on an N95 mask
McEvoy also has issued very specific guidance to patient care providers. "They should be asking for information from the dispatcher about respiratory illness, if it has not been given, and they should not walk within 6 feet of a patient who potentially has a respiratory illness without asking if they have a fever," he says. "If the patient can't answer, or if they say yes, they should put on an N95 mask."
He also has asked providers to limit any actions that could cause patients with respiratory illnesses to spread droplets or respiratory secretions. "For example, if people have trouble breathing, they often give them nebulizer treatment and sometimes suction out secretions," says McEvoy. "We recommend they not do that unless it's absolutely necessary."
He also suggests that if ambulance patients are thought to be infectious, the EMS should not simply bring them in, but call ahead and then leave them in the ambulance until hospital personnel tell them where to go "so they do not spread germs all over the ED," McEvoy says.
He's taking these actions "not because we suspect we will have a wild and crazy outbreak, but because there are just so many unknowns."
For more information on H1N1 preparation and response, contact:
Will pandemic keep staff home?
Whenever the possibility of a pandemic arises, ED managers and other health care professionals wonder whether they will have adequate staff to treat patients or whether many staff members will stay home for personal reasons. As the current outbreak of H1N1 shows, there are no easy answers.
"We've had about 25% more call-outs than usual this week, but I'm not sure that's why," says Charles Pattavina, MD, FACEP, chief of emergency medicine at St. Joseph Hospital in Bangor, ME.
But David Ross, DO FACEP, an emergency physician at Penrose Hospital in Colorado Springs, CO, and a spokesman for the American College of Emergency Physicians (ACEP), says, "We have not seen any absenteeism in our hospital; it's been business as usual. The staff has looked at which precautions we should take in what circumstances, and everyone has shown up ready to work."
Nonetheless, absenteeism could be a serious issue, warns Katherine West, BSN, MSED, CIC, infection control consultant, Infection Control/Emerging Concepts in Manassas, VA. "I saw a survey of nurses in the San Francisco area where more than 50% said they would not come in, so this is where we have to begin preparation," West cautions.1 "We have to assess our own workplaces hardcore and see who would come to work."
To do this, she says, it's important to ask your staff in ways that will not identify them. "You have to somehow get an honest assessment," West says. "You can get all the plans in the world, but if you do not have adequate staff, it is problematic."
In addition, she says, it's important to survey staff readiness at home. Have they planned for child care, elder care, or pet care? "You need to make sure people have been doing that preparation," West asserts.
The Centers for Disease Control and Prevention (CDC) is an excellent source for the latest information on H1N1. At www.cdc.gov/swineflu, you will find consumer and provider fact sheets, current information, and steps you can take to protect yourself against infection. You will also be able to download a widget that you can post to your own web site to help your patients get the most current and accurate information. At www.cdc.gov/swineflu/guidelines_infection_control.htm, you will find the latest available guidelines.
The World Health Organization (WHO) is posting information at www.who.int/csr/don/en.
The Association for Professionals in Infection Control and Epidemiology (APIC) also provides valuable information about H1N1. Check out their web site www.apic.org. At the top of the page, select "Emergency Preparedness" and then "Swine Flu Information."
‘Reverse triage' adds to surge capacity
Process more reliable than added staff, resources
A new study published online ahead of print in Disaster Medicine and Public Health Preparedness indicates that a process called "reverse triage" contributed to 50%, 55%, and 59% of the creation of surge capacity respectively in three hospitals in a single health system in Maryland.1 The researchers canvassed inpatient units for 19 weeks at the three facilities. Any patients who did not require any critical intervention — used as a proxy for a consequential medical event — within four days of the hypothetical disaster were deemed suitable for early discharge.
The concept is not entirely new, explains Gary Green, MD, MPH, MBA, vice chair of emergency medicine and director of simulation services for the NYU Langone Medical Center in New York City and one of the authors of the paper. Green was with the Johns Hopkins system when the research was initiated. "The military used it initially in considering how they could get people back to the battlefield, and others have suggested that the poor minorities in New Orleans were the victims of reverse triage," he notes, "but we use it in a very different capacity; it's triaging at the exit rather than at the entrance."
There are several options for increasing surge capacity, Green notes. You can increase resources, decrease demand, or change the way you distribute resources to meet demand. "Traditionally, we have focused on increasing resources, but that's problematic because in most disasters the ability to increase them just won't be there," he says. Green says following the lessons of Katrina, The Joint Commission and other national organizations recommend that hospitals expect and plan to surge in place for up to four days.
"In terms of increased staffing, you may not have that ability during a major event. Staff may not show up because they're concerned about their family, they're injured, or they're cut off from the hospital," Green says. "You won't be able to surge in place; that's where reverse triage comes in."
In an ideal situation, says Green, hospital staff would have an evidence-based computer model or some other predictive instrument to determine the risk of subsequent adverse events for patients they are considering discharging early. "It does not yet exist. Our team is working on developing that instrument," he says. In the absence of such a model, the researchers developed a "proxy" in an earlier study where they used an expert panel of clinicians and hospital leadership to create consensus guidelines and recommendations. "They came up with a ‘magic number' of 12% risk of an adverse event in the next four days as acceptable to release to the community or transfer to home," Green shares.
Andrew Milsten, MD, MS, FACEP, disaster medicine fellowship director at the University of Massachusetts, Worcester campus, says, "This is a good approach. It's a good start to showing how to get people out quickly, but it's not a cure-all." For example, he points out, if you have empty beds but insufficient staff to treat the future patients who would fill them, you still have a problem.
For more information on reverse triage, contact:
Implications seen for ED staffs
When hospitals adopt a reverse triage policy as part of their disaster response plan, it has direct implications for ED leadership, says Gary Green, MD, MPH, MBA, vice chair of emergency medicine and director of simulation services for the NYU Langone Medical Center in New York City and one of the authors of a paper in Disaster Medicine and Public Health Preparedness describing the process.1
"One way this process could be applied is on admission on a daily basis, where admitted patients are assigned a reverse triage score, and that would presumably be done by the ED attending," says Green. "Then, it would be updated on a continuous basis on daily rounds or via a computerized system." he says at Bellevue Hospital, one of the New York City facilities he supervises, the routine admission paperwork includes a space for the reverse triage score.
"The ED's role would also be to manage patients coming in and sending home rapidly anyone who does not need to be there," adds Andrew Milsten, MD, MS, FACEP, disaster medicine fellowship director at the University of Massachusetts, Worcester campus. "In terms of who is to be admitted, if someone comes in that's in a ‘gray' zone, a ‘soft admit,' where you might be more inclined to send them home, there might be more transfers out of the ED to other hospitals."
Green agrees. "Reverse triage can be applied to a department, as well as to a hospital or a system," he says. "But you do not want to discharge someone unless the incoming patients have a higher risk, and you need to be able to stratify that risk."
Finally, says Green, since ED nurses, physicians, and managers are the "natural experts" in critical event preparedness and often the leaders in overall hospital response, "they should be aware of this work and be proposing at their hospitals and medical centers that they consider whether this type of frame would work for them." He adds that they should have discussions with hospital staff and other departments and encourage them to consider it, "since this identifies that the greatest capacity you can potentially gain is by reverse triage than by other means that have traditionally been identified." [Editor's note: Have you instituted effective surge capacity strategies in your facility? Let us know about it. Contact: Steve Lewis, Editor, ED Management, at (678) 740-8630. E-mail: firstname.lastname@example.org.]
Don't forget the individual patient
The reverse triage approach described in an online article in Disaster Medicine and Public Health Preparedness1 makes sense — to a point, says James J. Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians, an emergency physician partnership group in Canton, OH.
"If you have to address a community emergency, you first look to internal capacity within the institution, and that would have to include the possibility of moving patients out," he notes.
However, Augustine adds, "It has to be situation-specific and up to the individual physician, patient, and family, and the facility that may or may not accept the [transferring] patient," because there can be so many different types of situations. For example, he says, a patient might be brought into the hospital for elective surgery. An emergency occurs, other patients become infected, and the patient himself decides he doesn't really want to be there. "Or a patient may be nearing discharge anyway, and the physician knows they can safely be discharged out of the hospital and have a place to go," Augustine suggests.
Families also are an important consideration. "The family may want to evacuate out ahead of the disaster," he offers. "On the other hand, there may have been a wildfire. You would normally discharge a given patient to make room for more seriously ill patients, but the home has been affected and the family has nowhere to go themselves."
For more information on patient/family considerations in reverse triage, contact: