EXECUTIVE SUMMARY

With influenza season intensifying, many EDs report strong surges in flu-related volume. Although illness severity does not appear to be atypical, hospitals that see high numbers of older patients and the chronically ill face extra challenges meeting the needs of patients who have added susceptibility to flu-related complications. Experts note that all flu strains circulating this year appear to be sensitive to antiviral medications.

  • In mid-February, the CDC reported the number of flu cases was still on the increase in most regions of the country, with 28 states reporting a high incidence of influenza-like illness.
  • Hospitals in Portland, OR, have instituted “zone management” multiple times — a process whereby ambulances are supervised closely and redirected so that individual hospitals do not become overwhelmed.
  • EDs in both Pennsylvania and Missouri report that flu-related volume is much higher this year than in 2016.
  • The vast majority of flu cases this year involve influenza A (H3N2), although the CDC notes that influenza B viruses also are circulating.

EDs in multiple states report they are seeing many more cases of the flu this year than during the 2016 season, creating capacity challenges in some regions. By mid-February, the CDC noted that the number of influenza cases was still on the increase in most regions of the country, with New York City and 28 states reporting a high incidence of influenza-like illness (ILI), and with Puerto Rico and an additional seven states reporting moderate levels of ILI. (For more data, please visit: http://bit.ly/2jz6CXx.)

Although the vast majority of cases reported this year involve influenza A (H3N2), the CDC reports that influenza B viruses also are circulating, albeit in much smaller numbers. The CDC notes that this year’s vaccine appears to be about 48% effective, and there is no doubt the vaccine remains the best way to prevent infection and related complications. Nonetheless, by mid-February, many EDs were reporting strong surges in flu-related volume, and it was unclear if the incidence of flu had yet peaked. Although the severity of illness associated with this year’s predominant strain is fairly typical, EDs that treat large numbers of older patients and the chronically ill have faced additional challenges in meeting the needs of patients who are more susceptible to flu-related complications and recover slower than younger, healthier individuals.

Coordinate with Other Hospitals

Although Oregon has not been cited by the CDC as one of the states hardest hit by influenza, many hospitals there are definitely feeling the strain. In Portland, for example, hospitals have been so inundated with flu-related volume that they frequently have had to go on what they call zone management, a process during which administrators exert tighter control over where ambulances are directed so that no one hospital is completely overloaded.

“When hospitals get full, they begin to divert, but when everybody is full, then all the hospitals have to basically open up again,” explains Mohamud Daya, MD, MS, the EMS section director in the department of emergency medicine at Oregon Health and Science University Hospital (OHSU) in Portland, OR. “So we have had a lot of redirection of ambulances to different hospitals, and that has kept us busy, so it has been a pretty tough situation.”

Daya notes that Portland has a fair number of hospitals, but they have all had to work together to manage the influx of flu patients. “We have phone calls where the public health folks have brought together all the hospitals to see our status on where we are, and consider what we can do to try to reduce some of the overcrowding,” he says.

The flu, primarily the H3N2 strain, arrived in Oregon early this year with the first cases presenting in December 2016, says Daya. However, he observes that the main problem has been the large number of elderly patients who have comorbidities that put them at high risk of complications from the flu virus.

“The biggest thing we are seeing is a lot of older patients with shortness of breath and fatigue who are unable to have enough intake, and so they get into trouble,” Daya explains. “If you have been living with a chronic disease and you get an acute illness like the flu, it doesn’t take much to kind of tip you over, and then you lose control and you lose the ability to manage and take care of yourself.”

Consider Needs of Complex Patients

Daya clarifies that he has not seen many cases of the flu that are associated with secondary pneumonia. “We had that a few years ago where people [with the flu] also had bad pneumonia. I have not seen a lot of those cases, but I have seen a lot of people debilitated and worn out,” he says. Daya adds that when a flu patient presents with an underlying problem, such as lung disease, asthma, kidney disease, or diabetes, the problem becomes more serious, often requiring additional support and hospitalization.

Further, these older patients, many of them from care homes, take longer to recover from flu and related complications, piling more strain onto the healthcare system, Daya explains.

“They are not the young and healthy who might be able to get along just by staying home and taking oral antiviral medications,” he says.

When the hospitals are full of inpatients, that leads to backups in the ED, and there is not a lot of slack in the system to accommodate surges in demand, Daya says. “We try to run very efficiently with high occupancy rates and keep our beds filled, so we don’t have a lot of room to take on a surge of flu patients,” he explains. “That has been a telling lesson for me.”

OHSU Hospital is an academic teaching hospital with a 43-bed ED that sees roughly 50,000 patients a year, Daya observes.

“Being a tertiary academic center, we tend to take care of a large number of what I would call complex medical conditions, so my experience could be very different from some other hospitals,” he says. However, Daya notes than any hospital that sees a large number of elderly patients or patients with underlying comorbid conditions probably faces similar challenges. “These patients have a very hard time when they get sick,” he adds.

Be Alert to Atypical Signs

OHSU Hospital has taken several steps to prevent the flu virus from spreading when patients present for care, beginning with the provision of flu vaccinations for staff, most of whom have received the shots, Daya notes. In addition, when patients suspected of having the flu present for care, staff put them on what the hospital refers to as droplet precautions.

“Most of the time ... the flu is spread by large droplets, so when a patient sneezes or coughs, the droplets go in the air, then they settle, and somebody else touches or inhales them and picks up the virus,” Daya explains. “So we try to get them to wear a mask, and then we wear a mask when we are in the room with them.”

Daya, who frequently works with the ambulance system, says that the same approach is encouraged among the paramedics when they are responding to calls that involve patients suspected of having the flu. However, Daya acknowledges that not all cases of flu present with typical symptoms. “Sometimes, the symptoms are pretty straightforward: pains, fevers, chills, coughs, sore throat, and runny nose,” he says. “However, other times, the flu can present slightly differently.”

For example, transplant patients or patients who are immune-suppressed may not always present with the telltale symptoms of flu, and so precautionary steps are delayed. “We prefer to do them up front, but the diagnosis is not always clear,” Daya says.

Along with cases of the flu, emergency providers also have seen a fair number of patients with norovirus, a gastrointestinal ailment that is highly contagious, requiring very strict staff precautions.

“There, you have to use contact precautions so you use a mask and a gown,” Daya says. “You make sure you wash your hands both before and after [interaction with the patient].”

In cases in which clinicians are very worried about contagion, they may place the patient in a negative pressure room, but Daya notes that OHSU Hospital only has six such rooms available in the ED, so it is not a solution that can be implemented on a large scale.

Although the flu season has been tough this year in Portland, Daya offers a bit of good news.

“The flu strains are all still sensitive to the antivirals that we have ... and one of the antiviral medications is generic and so it cheaper,” he says. “We struggle with overcrowding, but I think on the flip side, we have some good things that have helped with our ability to deal with it as physicians.”

Emergency providers in Pennsylvania have seen a big surge in cases of the flu compared with the same period last year, according to David Burmeister, DO, FACEP, CPE, chair of the department of emergency and hospital medicine at Lehigh Valley Health Network in Allentown, PA. “The volume [of flu cases] has pretty much doubled compared to what it was last year across the entire state,” he explains. “It has been a very heavy flu season ... and on top of that, we have had quite a bit of norovirus as well.”

Burmeister notes that for both January and February, the 60-bed ED at Lehigh Valley Hospital — Cedar Crest has been running at about 5% above its budgeted patient volume. It has been a challenge, but one the hospital has been able to manage primarily through staffing adjustments.

“We have upped staff from an emergency medicine standpoint on certain days that we know are going to be high-volume days,” he says. For example, Burmeister notes that Mondays are always very busy in the ED, so administrators schedule more personnel to work on those days.

A newly streamlined admissions process, which was just implemented in November 2016, also has made a difference in helping emergency staff expedite admissions, thereby creating capacity.

“We have been able to improve flow through the ED by improving the flow of the system overall,” Burmeister observes.

For instance, he notes that administrators have worked with transporters, the people responsible for cleaning the beds, and bed board staff to eliminate unnecessary steps and delays. “All of those smaller pieces that add up to wasted time we have tried to minimize as much as possible,” he says.

Such improvements have been somewhat easier to accomplish in a department that is comprised of both emergency medicine physicians and hospitalists, Burmeister notes.

“Every place is a little bit different in how they process admissions, but with us being one group, one department, we are able to collaborate on a daily basis,” he says.

Although the number of flu cases has been high, the severity of this year’s flu and the presenting symptoms have been fairly typical, Burmeister notes. “We tend to use our ECMO [extracorporeal membrane oxygenation] during the peak of the flu season more than during the rest of the year, but [there has been] nothing out of the ordinary [this year],” he says.

Highlight Infection Control Practices

The University of Missouri Health Care also reports a surge in flu cases in the ED this year, according to Christopher Sampson, MD, FAECP, an emergency physician at University Hospital in Columbia, MO. “We saw our big flu spike in March of last year, but the highest number of cases we had then was still less than what we saw the last week of January this year,” he says. “The first week of February, we had over 100 cases of the flu.”

Along with cases of the flu, the hospital is seeing an uptick in patients presenting with a gastrointestinal virus that typically lasts for 24 to 48 hours, and then resolves, Sampson explains.

So far, the ED has been able to manage the influx without boosting staff, but clinicians are taking steps to prevent the flu virus from spreading. “If we are concerned that patients have the flu, they get a mask when they check in,” Sampson notes. “Patients are also advised about general good hygiene, such as covering their mouths when they cough or sneeze, and also good handwashing — basic steps that we always tell people when they are discharged.”

Although the volume of cases has been challenging, the illness severity has not proven to be as problematic as it has in some previous flu seasons, Sampson notes.

“Two or three years ago, there were people coming in with post-viral pneumonias, but this year, so far at least, we have seen that the majority of patients are able to go home with just conservative management,” he says. “We are not seeing a lot of the complications that require people to be admitted.”

SOURCES

  • David Burmeister, DO, FACEP, CPE, Chair, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, Allentown, PA. Phone: (484) 862-3232.
  • Mohamud Daya, MD, MS, EMS Section Director, Department of Emergency Medicine, Oregon Health and Science University Hospital, Portland, OR. Email: dayam@ohsu.edu.
  • Christopher Sampson, MD, FAECP, Emergency Physician, University Hospital, Columbia, MO. Email: sampsonc@health.missouri.edu.