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Flu scare shows strengths and weaknesses from providers
Risk managers should assess response, prepare for next time
The nation's most recent scare with the H1N1 flu virus showed both the good and the bad of health care providers' preparations for a serious pandemic, and the assessments are largely positive. Risk managers analyzing their own organization's response likely will find much to be proud of and a few areas that could use improvement, says Maurice A. Ramirez, DO, BCEM, CNS, CMRO, an emergency physician at Pascoe Regional Medical Center and president of the consulting firm High Alert, both in Kissimmee, FL.
There is no doubt that the H1N1 scare in the first half of 2009 gave American hospitals a test run for their epidemic readiness. Hospitals in Long Island, NY, reported a 50% surge in ED visits, forcing a scramble to find enough health care workers to handle the influx. The Hospital Association of California reported that hospitals in the Los Angeles area experienced a 12% increase in ED visits. A hospital in Galveston, TX, near the Mexican border, ran out of flu testing kits early in the season after being swamped with patients worried that they had the H1N1 flu. Loma Linda University Medical Center in San Bernadino, CA, set up a tent in the parking lot outside the ED to handle the sudden surge in patients fearful of the flu. Children's Memorial Hospital in Chicago saw 394 children in its ED one day, more than double the typical number.
Almost all of the patients swarming EDs around the country turned out to have nothing more than a routine case of the sniffles or a less dangerous strain of the flu, and many were not sick at all but worried by the hype about H1N1. Most hospitals responded by isolating patients reporting flu symptoms, and handing out masks for them to wear while at the hospital.
Ramirez points out that, while it may seem the early 2009 flu scare is done or ending, that isn't necessarily the case. The flu could surge again and bring far more cases than the country saw earlier, either as a resurgence of the swine flu, the avian flu, or a combination of the two. Next year's flu season also could be more severe.
"The general pandemic scenario involves a pre-pandemic, a mini version if you will, that hits the season before the true pandemic really takes place," he says. "It keeps burning through the population worldwide and building the number of cases until the next season when it really takes off."
Risk managers should be sure that their organizations are not letting their guards down, Ramirez says. In particular, he says, remember how some providers handled the recent severe acute respiratory syndrome (SARS) scare.
"You must be certain that you are continuing your pandemic plans, particularly by continuing the surveillance," he says. "There are hospitals that stopped doing the tests to confirm it is H1N1 because they were afraid of being labeled a swine flu hospital, in the same way that hospitals in Toronto were labeled SARS hospitals and saw a dropoff in patronage as a result. You cannot let public relations, public image concerns, govern public health."
Without the surveillance, you may have flu spread to your staff, and you will quickly lose personnel, he notes. You also are unable to properly report flu cases if you are not vigilant about surveillance.
"Remember, they executed two people in China for not reporting SARS," he says. "You don't want people pointing fingers and deciding who to fire the corporate equivalent of being executed over having made a decision to not act in the public's best interest. That is a public relations nightmare that no one in this health care industry will want."
Avoid flu hysteria
Ramirez says he would give the health care community generally good marks for its response to the H1N1 flu, though there were instances of overreaction that fed the public's hysteria and led to overcrowding in EDs. He heard reports of some health care providers going "Tamiflu-crazy" with 10,000 prophylactic prescriptions for the anti-flu medication in the first 10 days of the flu scare, before there had even been 200 cases reported nationwide.
Some EDs acted with more paranoia than reason, Ramirez says. Activating a flu pandemic plan is justified, he says, but then the plan must be carried out in a reasonable manner. He saw some EDs putting masks on all children who showed up with a cough, which he says is overkill and counterproductive unless the masks are used properly which they almost never are. Masks must be replaced every four hours, placed on the face whenever the wearer is near another person, and not removed for convenience when eating or drinking, among other rules.
"Masks on patients are supposed to be N95, not the little things with loops behind the ears. Those are useless," he says. "One of my colleagues at the CDC refers to those as 'tissues with handles.' Instead of throwing that tissue away, you keep it hanging on your face for 12 hours. I see health care workers take them off and let them hang from their neck. So now, they're just inhaling all the stuff that was on the outside of that mask."
On the positive side, Ramirez says most health care organizations saw an increase in good hand washing technique because of the flu. He suggests that risk managers push for a reasonable response to flu concerns, which may involve pulling back on some standard ways of operating in the health facility.
"There's been a big push for family presence in recent years, with the idea that we want those patients surrounded by family and friends," Ramirez notes. "That's all well and good in a normal situation, but the hospital has to be ready to say that in a Level 5 pandemic, having all those people around is not a good idea. The risk manager needs to be a voice of reason to say we can respond appropriately but without making it look like we're in a panic."
One of the lessons learned from the flu season was that you never know when a potential disaster will strike, and you must ensure that your organization is always ready, says Carol Burkhart, RN, MS, CNP, a senior vice president in Marsh's Health Care Consulting Practice in Denver.
"We always talk about preparation in health care, but we have to ask the hard questions about whether we have all the necessary equipment and whether our personnel are really prepared to respond effectively," she says. "In a situation like a pandemic flu, we find out very quickly whether we are or aren't."
The flu also highlighted the need for a good media response plan, Burkhart says. In the early 2009 flu season, the media hyped a lot of misinformation and led the greater fear among the general public than was warranted, she says. That, in turn, led to too many visits to EDs that, if flu really were present in the community, could have just spread the flu to the worried well who went and sat in the waiting room with the truly sick.
"There was a lot of confusion in the community, so it behooves risk managers to make sure their organizations can stem that tide and respond appropriately with information from your media department that counters some of the misinformation," Burkhart says. "Your people will be viewed as the local or regional experts, so they need to be ready and informed enough to be the voice of reason, the voice of fact and not just worries and fears."
Burkhart says most of the health care operations she works with did operate their pandemic plans effectively.
"I think they could have been a little more aggressive in countering the misinformation from the media, but that would be my most serious criticism of the health care industry response," she says. "Overall, a good report for this experience, but we dodged a bullet this time. The next flu pandemic, in the fall or whenever it happens, may be much more severe than this one, and we will have to maintain a constant state of readiness."
For more information responding to flu epidemics, contact:
Carol Burkhart, RN, MS, CNP, Senior Vice President, Marsh Health Care Consulting Practice, Denver. Telephone: (303) 308-4512. E-mail: email@example.com.
Maurice A. Ramirez, DO, BCEM, CNS, CMRO, Kissimmee, FL 34744-5151. Telephone: (407) 301-3458. E-mail: Renaissancedoc@earthlink.net.