With flu widespread in every state except Hawaii, frontline providers have been busy this year trying to stay ahead of what is shaping up to be a robust flu season. To cope with spikes in volume, hospitals in some regions are canceling elective surgeries, restricting visitors, opening new treatment areas, and scrambling to stay ahead of staff and supply shortages. Some are diverting ambulances elsewhere to manage capacity.
Indeed, the flu arrived early, putting many hospitals on their heels by the end of December, and with the number of flu cases way up, flu-related complications have spiked, too. Hospitals in Colorado reported nearly triple the usual number of flu-related hospitalizations in late December. Similar reports have emerged from other states.
The Chicago Fire Department added five ambulances to handle the flu-related surge in the first week of January, and hospitals there have been reporting much higher volumes than what they experienced last year.
Of particular concern is the number of flu-related deaths confirmed in children. By mid-February, the CDC noted that 84 children had died from flu-related complications.
Push Flu Vaccinations
Most cases of confirmed flu thus far have involved the H3N2 strain, a cousin to the swine strain that caused a big outbreak in 2009, explains Bettina Fries, MD, FIDSA, chief of the division of infectious diseases at Stony Brook Medicine in Stony Brook, NY, a health system that includes three hospitals and several other health centers on Long Island. However, she notes there is evidence from Australia that there could be some drift in the strains that are circulating. “These strains all have so-called segmented genomes. That means their genomes are made up of eight separate pieces of DNA, and they can basically mix and change,” Fries notes. “What we see a lot of times is that the strains change over the course of the flu season, and that can sometimes make them different at the end of the flu season.”
In mid-January, the number of flu cases still was on the rise in most regions of the country, according to the CDC. That is in line with what Fries is observing in her own setting.
“Right now, we are having a lot more admissions related to flu, and whether this is the result of a less efficacious vaccine or whether this is just a more potent strain, time will tell,” she says. “However, even if the vaccine is not as efficacious, we still want to very aggressively pursue vaccinating as many people as possible because flu vaccines in general are usually only between 30% and 60% efficacious, but there is still a huge benefit if you decrease the number of patients that present with flu and the time in which they are infected with the flu virus.”
Fries urges providers to be especially concerned with patients most at risk for flu complications.
“The patients with the highest mortality are elderly patients over the age of 65 and patients that are immune compromised,” she says. These include patients on chemotherapy or other drugs that suppress the immune system. Also of concern are patients who are obese, very young children, Native Americans and other ethnic groups known to be at increased risk for flu complications, and patients with underlying respiratory problems such as asthma.
The challenge for frontline providers is staying ahead of spikes in flu-related volume because flu spreads very quickly, Fries observes. “The big problem with flu from a public health point of view is that once the genie is out of the [bottle], it is extremely difficult to contain because patients are infectious about 24 hours before they present [with symptoms],” she explains. “That is why in 2009, when we had this big pandemic, [the flu] popped up in a few places in New York and then all of a sudden everybody had it.”
Add Treatment Areas
Clinicians at Stony Brook University Hospital are aggressively screening patients with upper respiratory symptoms for viral infections so that they stay on top of their own numbers.
“We are not only seeing flu. We are seeing other respiratory infections as well,” Fries adds.
Sharp Grossmont Hospital in La Mesa, CA, began seeing a steady trickle of patients with the flu before Christmas, but that quickly turned into a deluge immediately after the holiday.
“We came back on [Dec.] 26 to an ED that was inundated with patients with flu symptoms,” explains Marguerite Paradis, BSN, RN, MHA, the director of emergency services and critical care at the hospital. “We usually don’t have patients waiting in the waiting room in the morning because we usually can get everyone seen. When we came in on the 26, there were 50 patients waiting in the waiting room, which we had not seen in a very long time.”
There were even more patients in the waiting room the following morning, and that opened everyone’s eyes to the challenge that lay ahead. “We knew we were not going to decompress. We couldn’t even decompress from the day before,” Paradis recalls. “Our average daily visits are around 280 or 290, and that week, starting on the 26, we went up to about 360 visits.”
To manage the surge, ED personnel fully leveraged a rapid treatment center that had been implemented in the department to take care of lower acuity patients.
“It became basically our flu clinic at the peak of the flu season for patients who were not severely ill from the flu,” explains Julie Phillips, MD, FACEP, medical director of the ED at Sharp Grossmont. “We had been seeing 30% to 38% of patients in the ED in that area, but during the peak of the flu we probably saw about 50% of patients there, and most of these patients didn’t require anything other than rapid treatment and diagnosis.”
Additionally, on Dec. 27, the ED constructed a surge tent in which staff assembled a second rapid treatment area.
“We were worried that we would not be able to assess all these patients in a timely manner without an extra treatment space,” Phillips observes. “We were seeing things other than flu there, but it went up and we needed the extra space because of the volume of flu patients we were seeing. It became a second minor treatment area.”
During peak times, the ED was seeing more than 20 patient arrivals per hour, Paradis says.
“Probably at least one-third of our patients were impacted by the flu,” she says, noting they were not all low-acuity patients. “We saw a lot of very sick patients affected by the flu, and of course many patients were admitted to the hospital, so we were holding two or three times the [usual] number of admitted patients waiting for beds in the ED.”
Stay Alert to Complications
Many of the more severe cases involved elderly patients who were just too sick to be cared for at home.
“What happens when the flu becomes quite severe is patients may become very short of breath and they can get secondary pneumonia,” Phillips notes. “Some of them may need a ventilator because they can’t breathe anymore. Some of them may need oxygen because they are just not getting enough into the lungs.”
A second problem that can occur is patients will become dehydrated and their blood pressure will decrease, leading to a cascade of other problems.
“Once you have low blood pressure, that is when things really start to get out of control really quickly, and that is when patients can become septic,” Phillips explains.
While it is not clear yet to Phillips if this year’s flu is actually more severe than in a typical year, she knows that it seems worse because so many more patients are getting sick.
“I am not sure if each patient is much sicker than they would be with other strains. It is just that the volume has added more sick patients to the ED and more sick patients in the ICU than what we typically see,” she says.
However, there are promising signs that the peak of this year’s flu season, at least for Sharp Grossmont, has passed. By mid-January, flu volumes were roughly one-third of what they had been earlier in the month, although clinicians certainly expect to see flu patients for many weeks to come.
“We still have patients coming in with the flu continually. Some will be very, very sick, and some will be more minor,” Phillips says.
While the flu surge may be over for Sharp Grossmont, Phillips believes that the array of strategies the hospital used to manage flu-related capacity issues can work for other hospitals, too. In particular, her advice to clinicians is to take appropriate steps to protect themselves.
“Providers need to know that this is a pretty nasty strain of flu, and they need to stay healthy so that they can continue to help take care of the community,” she explains. “You need to wear a mask.”
Also, consider added steps to protect patients. For instance, Sharp Grossmont has been offering hand sanitizer and a mask to everyone coming into the ED, Paradis notes.
“When you have these overwhelming volumes, patients are in close proximity to each other, and you have flu patients combined with non-flu patients,” she says. “I think trying to keep these groups segregated is helpful.”
Working with the hospital communications team to keep the community well-informed about flu outbreaks can help manage both volume and patient expectations. For instance, Sharp Grossmont used newsletters, social media, and interviews with local news outlets to keep area residents informed about all aspects of the outbreak, including what a typical flu course involves, who is most at risk, when a visit to the ED is necessary, prevention tips, and what to expect when patients do present to the ED. Further, the hospital translated its flu-related messaging into multiple languages for diverse communities.
“We also had to educate about hospital visitors,” Phillips explains. “Children aged 12 and under were totally restricted. Also, if anyone had flu symptoms, they were not permitted to visit a patient in the hospital.”
If an ED is going to be busy with lower-acuity patients, opening additional treatment areas can work well in managing the volume, Paradis advises. She notes that the strategy worked well for Sharp Grossmont, first when staff set up a second rapid treatment area in the surge tent, and then later when they created a second treatment area within the main ED.
“We just replicated our accelerated care process,” she adds.