Hospitals must rally to protect health care workers in case of flu pandemic

HHS: Plan for vaccines, antivirals, HCW support

The health care work force is taking center stage in the nation's pandemic influenza planning.

The U.S. Department of Health and Human Services' (HHS) Pandemic Influenza Plan paints a dire scenario of sick patients flooding hospitals — 30% of the U.S. population will become ill with pandemic influenza, half of whom will seek medical care. A severe pandemic, similar to the 1918 flu, would result in 9.9 million hospitalizations and 1.9 million deaths.

Local communities may be largely on their own as outbreaks occur throughout the country. "A vaccine will not yet be available, and the supply of antiviral drugs will be limited. Local outbreaks may last for weeks or months, and widespread illness in a particular community could lead to shortages in the health care sector, as well as in essential services," according to the plan, released by HHS in early November.

In a response to the pandemic, health care workers will be among the most essential resources. The plan acknowledges the importance of occupational health with a section that begins, "The ability to deliver quality health care depends on adequate staffing and optimum health and welfare of staff." (See checklist.)

Health care workers with direct patient contact are in the top tier, or highest priority, for an available vaccine, and are ranked just behind their seriously ill patients for antiviral medications to treat the disease. But beyond that, hospitals must make sure employees have sufficient training on pandemic influenza, access to adequate supplies, and psychosocial support. The plan says hospitals should "consider stockpiling enough consumable resources, including masks, for the duration of a pandemic wave (six to eight weeks)."

If a vaccine becomes available against H5N1, the avian flu strain now circulating, the American Nurses Association would support pre-pandemic vaccination of health care workers, says Cheryl Peterson, RN, MS, senior policy analyst. "We want to preserve the nursing work force so they are able to provide patient care should there be a pandemic influenza," she says.

The continued spread of avian influenza among poultry and wild birds fueled a growing sense of urgency this fall. States will take the pandemic influenza plan and provide even more detail on how to prepare, says Christian Sandrock, MD, MPH, assistant professor of medicine in the division of infectious disease at the University of California at Davis. Sandrock is helping draft the California plan. "Believe it or not, at 400 pages, it's a bit of a skeleton," he says of the national plan.

For example, the California plan will include guidance on whether exposed workers should be furloughed during a pandemic and how to set priorities in the event of a shortage of vaccine and antiviral medications, says Sandrock. Hospitals will need to revise their emergency plans, developing specifics for pandemic influenza. He advises hospitals to gather a team of people to play a key role in a pandemic and to work with the county health department and other hospitals.

"Although we have a plan and we have tested it and drilled it, clearly we're going to have to do more planning," agrees William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University in Nashville, TN.

As these plans take shape, employee health and infection control experts shared some basic areas of focus:

• Develop a system for mass vaccination.

At Baystate Health System in Springfield, MA, Director of Occupational Health and Safety James Garb, MD, is dusting off the smallpox vaccination plan and revamping it for pandemic influenza. Baystate never vaccinated employees against smallpox because of the concerns about cardiac adverse events. But the three-hospital health system conducted a tabletop drill and worked out the logistics of mass vaccination.

"We have the mechanism set up, which space we would use, [and] which personnel and equipment [we would need]," he says. "We could unroll that mass vaccination plan on short notice, or give out antiviral medications."

The Centers for Disease Control and Prevention (CDC) offers guidance on setting up a mass vaccination clinic and recommends using templates designed for smallpox vaccination (www.cdc.gov/flu/professionals/vaccination/pdf/vaxclinicplanning0405.pdf and www.bt.cdc.gov/agent/smallpox/response-plan/files/annex-2.pdf).

• Work closely with local public health authorities.

Unlike SARS, influenza primarily will be transmitted in the community, not in hospitals. So every hospital will be facing similar challenges — finding adequate staffing, supply, and surge capacity. The planning must be communitywide, stresses Michael Olesen, CIC, manager, infection control at Abbott Northwestern Hospital in Minneapolis. "This should be a regional discussion," he says.

Some of your staff or physicians may work at more than one facility. Which one would they report to in the case of a pandemic? If your plans call for opening an off-site facility to care for the overflow of patients, how will you staff it?

Meanwhile, Olesen cautions, you'll have to consider medical equipment, supplies, and other resources, along with staffing issues. Occupational health can be a part of discussions that would include personal protective equipment and vaccine availability, as well as patient care issues such as potential ventilator shortages. "With the potential volume of patients, there are not going to be enough medical supplies," he says. "There's got to be some discussion about how we best ration the care."

Consider priorities for limited vaccine or antiviral medication.

Vaccine is the foundation of the national response to pandemic influenza, according to HHS Secretary Mike Leavitt. "The good news is we have a vaccine that's been developed by the National Institutes of Health. The bad news is we lack capacity to manufacture a vaccine in sufficient volumes and in the time frames necessary," he said in a press conference.

The United States will stockpile 20 million courses of the current strain of H5N1, he said. Vaccine will not be available for a specific strain of pandemic influenza for three to six months after it emerges, and protection will require two doses, according to the HHS plan. In fact, the doses required to provide immunity may be significantly higher than the doses used for seasonal flu — 90 micrograms compared to 15 micrograms, Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told reporters.

Adjuvants may boost the immune response and allow the use of lower doses, Fauci said. But since it's impossible to predict when a pandemic might occur, hospitals need to consider the possibility of severely limited supply.

Likewise, the federal strategy involves boosting domestic production of the antiviral oseltamavir and stockpiling of 20 million courses by the end of 2006 and 81 million courses by the summer of 2007.

There are about 8 to 9 million health care workers involved in direct patient care or who provide essential support services, such as housekeeping, dietary, and laboratory work, the plan states.

Deciding who among your health care workers should be first in line for a vaccine is a difficult task, says Schaffner. "We're having a very hard time trying to ascertain who does not have direct patient contact in our facility," he says. "We are inclined, if we have sufficient vaccine, to also make it available to the family of health care workers to ensure that the health care workers will actually turn up to give health care."

Provide training to employees.

Now is the time to provide information about pandemic influenza and to reinforce training about infection control and the use of personal protection equipment (PPE), employee health and infection control experts say.

For example, employees should be reminded about the proper way to don and doff PPE to avoid contaminating themselves, says Olesen. They also need to be aware that the virus can survive on contaminated surfaces, he says.

Employees need to understand, too, the basics of federal, state, and hospital-based pandemic plans so they can make their own preparations, says Peterson. For example, the national plan suggests that school closings may be a mechanism for containing an outbreak. But if schools are closed, who will care for the children?

"Individual nurses and others have to be responsible for making a plan with their families — should something happen, this is how we react and respond," she says.

Here are some other topics for training, according to the plan:

  • how to protect family members and other close contacts from secondary occupational exposure;
  • how to detect patients with influenza symptoms and to implement containment procedures;
  • respiratory hygiene and other infection control measures.

Some staff should be cross-trained to provide support for essential care areas, such as the emergency department or intensive care unit. Social workers, psychologists, psychiatrists, and nurses need to be prepared to provide psychological support to other employees during a pandemic, the plan says.

Seek support for your staff.

In a pandemic, some of your employees will be out due to illness. Others may stay home to care for ill family members. Still others may be afraid to come to work. Just when you need extra staffing to handle the surge of patients, you can expect some absenteeism. "If you look historically [in pandemics], you see anywhere from 30% to 70% absentee rates," says Olesen.

Health care facilities should be prepared to help their employees manage stress and cope with family issues, the national plan says. For example, they should consider providing "rest and recuperation sites" with snacks and relaxation materials. They should consider offering elder care and child care and help employees maintain communication with family members while they're working.

Hospitals need to look at their own institutional resources to put together the programs that address the needs of their staff, says Mark Russi, MD, MPH, associate professor of medicine and public health at the Yale University School of Medicine and director of occupational health at Yale-New Haven (CT) Hospital. "If those needs aren't met, or if people don't feel safe in their workplace during a pandemic, we will be without adequate staff," he says.

Providing sufficient personal protective equipment will be critical, says Peterson. "I think nurses will respond," she says. "They always have in the past."

[Editor's note: A copy of the HHS Pandemic Influenza Plan is available at www.hhs.gov/pandemicflu/plan/overview.html.]