As pandemic eases, EHPs look to the next one

Lessons learned: Stockpile and communicate

The collective sigh of relief was almost audible at the approach of the one-year anniversary of the start of the pandemic of novel H1N1 influenza. Hospitals had dodged a bullet. Despite shortages of respirators, delays in delivery of vaccine, and difficulties identifying and isolating patients swiftly, hospitals found that employees were able and willing to continue to report for work and care for patients.

Still, it isn't too soon for employee health professionals to begin reviewing what worked and what didn't — and preparing for the inevitable advent of the next pandemic.

"This pandemic isn't over yet . . . we're still responding," Anne Schuchat, MD, director of the Center for Disease Control and Prevention's National Center for Immunization and Respiratory Diseases, said at a press briefing at which she announced that there was no widespread influenza in any of the 50 states. But she noted that CDC is already looking ahead. "If we have the next pandemic, with an influenza virus like the [more virulent] H5N1 bird flu strain, we need to do a lot more than what we've done this year," she said.

Health care workers were not fearful of this H1N1 influenza strain, which was viewed as similar in severity to seasonal flu. But some weaknesses in the hospital response could cause problems in the future, such as a lack of adequate training of hospital employees and sick leave policies that don't reinforce the important message that employees should stay home when they're ill, says Robyn Gershon, DrPH, professor of sociomedical sciences and associate dean for research resources at the Mailman School of Public Health at Columbia University in New York City.

In an often-cited study from 2005, Gershon and colleagues found that less than half of health care workers (48%) would be willing to report to care for patients in an outbreak of severe respiratory distress syndrome (SARS).

Gershon notes that health care workers are "very devoted workers, but even they have limits.

This pandemic was fortunately very mild, but future pandemics might not be." Hospitals need to examine the recent experience — from the effectiveness of communications to the availability of protective equipment, she suggests.

"This pandemic helped us to identify ways we could effectively mobilize and respond to any severe respiratory-borne infectious disease threat; it also helped identify gaps that need to be addressed so that we meet the health care needs of patients, while providing the highest degree of protection for our health care employees," Gershon says.

Lesson one: Stockpiling matters

Some hospitals and health systems had used federal pandemic preparedness funds that were available from the Health Resources and Service Administration, along with other resources, to maintain a stockpile of protective equipment and antiviral medications.

For example, the Veterans Health Administration created stockpiles at individual medical centers as well as a national stockpile. "It affirmed my belief that it's very important to prepare ahead of time," says Lewis J. Radonovich, MD, and director of Biosecurity Programs for the Office of Program Development at the North Florida/South Georgia Veterans Health System in Gainesville, FL. "The VA did not run out [of supplies]. In fact, we have a substantial national stockpile that remains."

Hospitals facing supply shortages used surgical masks rather than the recommended N95 respirators for routine care. But as they scrambled to find respirators to fit employees who needed protection in the more risky aerosol-generating procedures, they often had to refit-test using models that were not the preferred brand or style.

Yale-New Haven (CT) Hospital had made a substantial investment in pandemic preparedness and went through half of its stockpile of 200,000 N95s. "It got us through the spring and the second wave," says Mark Russi, MD, the hospital's director of occupational health and associate professor of medicine and public health at Yale University.

Even so, the hospital ran out of the small size and needed to substitute a different model for some employees. The hospital is now replenishing its stockpile with a respirator, the 3M 1870, that comes in one size and has good fit characteristics, he says. "We will find money to replenish the stockpile because we all understand that it's important," Russi adds.

Until a novel virus is well characterized, hospitals need to err on the side of protecting workers, he says. "The challenge, of course, is to decide whether and when there is adequate knowledge of transmission characteristics and virulence to adjust PPE recommendations," he says.

Lesson two: Mask patients

Once patients were identified as having novel H1N1, hospitals sprang into action to cohort them with other H1N1 patients and to protect workers. But how many people did they expose before that happened? One hospital found that some patients would complain of asthma — and later would discover they actually had H1N1 influenza, says Gina Pugliese, RN, MS, vice president of the Premier Safety Institute, part of the Charlotte, NC-based Premier Inc. health care alliance.

At the height of the H1N1 outbreak, Yale-New Haven (CT) Hospital began asking all patients and family members who came to the emergency department to wear masks — regardless of whether they had respiratory symptoms.

"[Previously], we weren't very good at determining which people needed masks, and people weren't good at identifying themselves either," says Russi. "We were concerned that people wouldn't like it. Actually, they loved it because they felt safe themselves — they felt protected from others around them who might have had flu!"

Health care workers were safer, also, as they evaluated which patients needed greater infection control precautions. Emergency department employees wore N95 respirators if they cared for patients with respiratory symptoms, and if they were unprotected and spent at least five minutes in the room with a patient who later was identified as having H1N1, they received antiviral prophylaxis, he says.

The policy on masking patients as they arrived reduced the incidents of unprotected exposures, he says. "The real danger is the unidentified patient in which no personal protective equipment is used," he says.

Some hospitals set up tents (indoors or outdoors) to triage patients. Stanford Hospital in Palo Alto, CA, tested a drive-through triage in a simulation and declared it a promising strategy for future pandemics. The patients first stopped at a registration station, then moved on to a station where an emergency department nurse measured their vital signs. At the third station, the patients left their vehicles and sat on a cot in a screened and heated area, where they were evaluated by an emergency physician.

Finally, they stopped at a discharge station, where they received prescriptions or other discharge instructions. "In essence, the patient's vehicle provided a moving examination room that alleviates the delay inherent in turning over a fixed number of rooms and spaces," concluded lead author Eric A. Weiss, MD, an emergency physician and medical director of Stanford Hospital's Office of Service Continuity and Disaster Planning. The drive-through strategy also would minimize the risk of transmission of infectious diseases, he said.1

Lesson three: Evaluate policies

Now is the time not only to review and revise policies and procedures for pandemic response, but to record the lessons and observations from this novel H1N1 pandemic, says Pugliese. After all, the next pandemic could be rapidly upon us — or it could be a decade or more away.

"In the middle of taking action, it's often difficult to capture everything you want to do differently next time," says Pugliese. "It's important to [analyze] what you did and what you learned for the next generation [of health care workers]."

Hospitals need to consider everything from just-in-time fit-testing and training on new safety devices to human resources policies, she says. For example, some hospitals combine sick leave and vacation time into an annual bank of "paid time off" for employees. Employees may begin to count on the days as vacation leave — and may be more likely to go to work sick to avoid using up their time, she says.

Communication is another important component of the pandemic response. Hospitals should have a single source for updated information to help avoid confusion or mixed messages, she says.


1. Qureshi K, Gershon RRM, Sherman MF, et al. Health care workers' ability and willingness to report to duty during catastrophic disasters. J Urban Health 2005; 82:378-388.

2 .Weiss EA, Ngo J, Gilbert GH, et al. Drive-through medicine: A novel proposal for rapid evaluation of patients during an influenza pandemic. Ann Emerg Med 2010. Available online on Jan. 15, 2010. Accessed on Feb. 9, 2010.