With this year’s flu vaccine much less effective than hoped, with a migration of the predominant strain from the predicted strain, EDs in some regions are getting slammed with patients presenting with flu-like symptoms. Further, even hospitals with mandatory flu vaccination policies are having to scramble to cover the shifts of emergency personnel out sick with one of this year’s vaccine-resistant strains.
With a flu vaccine that is largely missing the mark, EDs around the country have their hands full with patients complaining of flu-like symptoms. The flu arrived earlier this year than usual, and by mid-January, it was still not clear whether the virus had peaked. Many EDs are struggling with staffing challenges as more personnel than usual are missing work because they have come down with the flu themselves. As a result, hospital administrators are stepping up infection control practices and urging vigilance with respect to hand hygiene and wearing masks.
- By mid-January, the Influenza Hospitalization Surveillance Network reported that there had been more than 9,900 hospitalizations related to laboratory-confirmed cases of flu since October 1, translating to an overall rate of more than 36 hospitalizations per 100,000 people.
- This season’s predominant H3N2 viruses have been particularly hard on children, with the CDC reporting that more than 56 children had died from the flu by mid- January.
- Hospital administrators also report that chronically ill patients are particularly vulnerable to the flu. In some cases, these patients are straining hospital resources as they often require higher-level, inpatient care.
While the flu arrived as early as October in some areas, by mid-January, flu activity was widespread in most states, according to the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. Further, the Influenza Hospitalization Surveillance Network reports that there have been more than 9,900 hospitalizations related to laboratory-confirmed cases of flu since October 1, translating to an overall rate of more than 36 hospitalizations per 100,000 people.
Perhaps most concerning, this season’s predominant H3N2 viruses have been particularly hard on children. Illness severity related to the flu was climbing sharply in mid-January with 11 flu-related pediatric deaths reported to the CDC during the week ending January 17. Thus far this season, a total of 56 pediatric deaths related to the flu have been reported, and it is still not clear whether the season has yet peaked.
Hospitals in Michigan report that chronically ill patients are another segment of the population that has been particularly vulnerable to this year’s influenza. “We are seeing an uptick in the number of patients who are getting the flu who are chronic diabetics, are in renal failure, have chronic liver issues, or heart failure,” explains Joyce Farrer, RN, MSN, the administrator of emergency medicine in the Henry Ford Health System in Detroit, MI. “So we are seeing a large increase in the number of patients we are admitting to medical intensive care from the ED.”
Farrer notes that the only patients being tested for the flu at Henry Ford Hospital are those who require antiviral medication and admission. She estimates that number at about 15 patients per day, or 7% of the daily volume in the ED. This influx, coupled with the fact that ED personnel themselves are coming down with the flu, has presented challenges. (Also see, “Despite positive new research findings, use of antiviral meds against the flu remains controversial,” p. 28.)
“I have anywhere from two to three staff [members] a day who are off sick, so now we have to staff up for the [added] volume and we also have to staff up to cover those staff members who are sick and at home with the flu themselves,” observes Farrer. “Every day we are adding additional staff, and this has taxed inpatient [resources], too. Usually around the holidays we have been able to shut down some units, at least for a short period of time, and give additional staff time off. We were unable to do that this year. We had to keep every bed open because the ED volume was high and our demand for beds was way up.”
The typical volume at Henry Ford Hospital is 260-270 patients a day, with about 22% of those patients requiring admission, but the flu has driven the admission rate up to 26%, explains Farrer. “Also, a lot of these patients are requiring a higher level of care because they have all these comorbidities,” she says. “The risk to the patients and the severity of their illness is much higher.”
Usually on Christmas or New Year’s day, the hospital will see around 100-150 patients in the ED, notes Farrer. “However, this past Christmas we saw 210 patients, and on New Year’s day we saw 222 patients,” she says. “We also saw a big uptick in our volumes on the day after [each of these] holidays.”
Prioritize infection control
Even before it became clear that this year’s flu vaccine was not a perfect match for the predominant strains in circulation, the hospital began efforts to limit transmission of the flu, explains Farrer. As early as September, the hospital’s infection control committee began posting signs that instruct patients and visitors to let emergency staff know immediately if they have any signs or symptoms of the flu. “We spell it out for them; the signs and symptoms are pretty simple,” she says. “These signs are posted at all the hospital entrances.”
In addition, a triage nurse who is stationed up front collects additional information. “We will immediately put a mask on [suspected flu] patients if they have not already done so themselves,” notes Farrer. She adds that emergency staff are also routinely queried about whether they have a fever or a cough, and they are continually reminded to wash their hands. (Also see: “Use mystery observers, staff input to boost hand-washing compliance,”)
With the volume of new flu cases coming into the ED, it is still not clear whether the flu season has peaked, but Farrer is hopeful that the worst of the season is behind Detroit. “We have eight EDs [in the Henry Ford Health System], four of which are hospital-based and four of which are non-hospital-based, and they are all packed,” she says. “We are very busy.”
Wear masks for extra protection
Wendy Gelbard, MD, the associate chair of clinical operations in the ED at the University of Rochester Medical Center (URMC) in Rochester, NY, needs no further evidence that this year’s flu vaccine is not a good match for the virus strains that are now circulating. She is among several ED staff members who have come down with the flu this season, a factor that has made dealing with the surge in influenza cases to this busy medical center more challenging than is usually the case. In fact, when ED Management caught up with Gelbard to discuss this year’s flu, she was home sick herself, still recovering from the virus.
“Our hospital is well above capacity, and it is worse this year than I can recall in years past,” says Gelbard. “The hospital is so full that we have more inpatients boarding in the ED because there are more inpatients in the hospital, and they are not leaving as fast as we admit them, so we have had to staff up.”
Gelbard notes that hospital administrators have helped the ED cope with the influx with more resources and personnel. “We have opened up alternative care areas where we are trying to provide care in areas that would not be considered conventional inpatient units,” she explains.
When a patient presents to URMC with symptoms that are suggestive of the flu, ED staff try to isolate him or her until the diagnosis is confirmed, explains Gelbard. “Handwashing and all the usual infection prevention methods are present and being pushed in the department,” she says. “Staff have to be vaccinated for the flu or, if not, wear a mask, but this year, because the vaccine has not been that effective, staff are voluntarily wearing masks in their areas,” notes Gelbard.
The ED at URMC first started seeing cases of the flu in November, but the surge became more serious the following month, says Gelbard. “In December, 40% of the flu swabs we sent [for testing] were coming back positive, so that is pretty high,” she says.
By mid-January, the percentage of flu swabs coming back positive was down to 20%, but it still wasn’t clear whether the decrease was going to be sustained.
Prepare for staffing challenges
The ED at Vanderbilt University Medical Center (VUMC) in Nashville, TN, has also seen more employees come down with the flu this year than is typically the case, but the number of patients presenting with symptoms of flu is in line with what providers are accustomed to seeing this time of year.
“For the month of December, we submitted roughly 1900 [flu swabs] for testing … and of those about 14% came back positive,” explains Emily McBride, MSN, RN, manager of the adult ED at VUMC.
When compared to the last two flu seasons, the numbers are slightly elevated, but not overwhelming, notes McBride. Further, unlike what emergency providers at Henry Ford Hospital and URMC are experiencing, flu patients who are presenting to the ED at VUMC this year don’t seem to be quite as ill as they have in recent years. “I don’t feel like we are admitting quite as many people as we have in the last couple of seasons,” observes McBride.
However, McBride notes that as she oversees the adult ED, her observations do not reflect how the flu has impacted pediatric cases this season. She adds that the adult ED sees about 180 patients per day, typically.
While flu volume and severity have not been unusual this year at VUMC, the season has come with some unique challenges. “The phenomenon I am noticing this year is that it seems like our nursing staff have had more cases of the flu among themselves, so we have had a couple of staffing challenges,” says McBride. “We have started to have two on-call nurses, so that when calls come up we have more than one person to rely on.”
Also, McBride notes that ED administrators have beefed up their infection prevention efforts. “We’re being more vigilant with hand hygiene, and our leadership team is doing hand-hygiene audits to reinforce that,” she says.
The ED participates in a hospital-wide peer-vaccinator program that enables members of the leadership team to administer flu vaccinations within the department, adds McBride. This has made it easier and more convenient for emergency staff to get vaccinated. “Our staff this year had to fill out a waiver form if they elected not to get vaccinated, and some of those waivers have been denied,” explains McBride. “Also, our occupational health department is monitoring that and sending out frequent reminders to those who have not been vaccinated.”
Editor’s note: Interestingly, none of the EDs contacted by ED Management for this article reported making use of Google Flu Trends, or any other new flu prediction tools, designed to help health care providers better anticipate demand. However, it is possible that some of the sources EDs rely on for predictive information, such as local health departments for example, may be looking to these tools for anticipatory guidance. Most EDs utilize their own census and markers of acuity, such as admissions, as a surveillance method for influenza and other community illnesses. Their data should help public health providers develop action plans for response to outbreaks of illness.
- Joyce Farrer, RN, MSN, Administrator, Emergency Medicine, Henry Ford Health System, Detroit, MI. E-mail: firstname.lastname@example.org.
- Wendy Gelbard, MD, Associate Chair, Clinical Operations, Emergency Department, University of Rochester Medical Center (URMC) in Rochester, NY. E-mail: email@example.com.
- Emily McBride, MSN, RN, Manager, Adult Emergency Department, Vanderbilt University Medical Center, Nashville, TN. E-mail: Emily.firstname.lastname@example.org.