Good contingency plans address severe flu outbreak

Prepare for the perfect storm this flu season

It’s a frightening combination: A severe vaccine shortage, more than 80 million Americans at high risk for flu complications, and a nationwide ED overcrowding crisis. These three factors mean that emergency nurses could be faced with the prospect of the perfect storm — a surge of critically ill flu patients and no resources to care for them, warns Arthur Kellermann, MD, chairman of the department of emergency medicine at Emory University School of Medicine in Atlanta.

The Dallas-based American College of Emergency Physicians has issued a national call to action to prepare the nation’s EDs for a surge of severely ill influenza patients.

"We all hope and pray for a mild flu season, but wishful thinking is a poor substitute for prudent planning," says Kellermann. (See resources, below, for materials to address a flu outbreak.)

"In December 2003, when the flu season hit us hard, we had to seek alternatives to ease ED overcrowding," says Sherry Walter, RN, MSN, CCRN, clinical director of the emergency care center at Northeast Medical Center in Concord, NC. Northeast saw almost 2,000 more patients than anticipated in that month alone, she says. "With the national vaccine shortage, there is the possibility that we may see a surge again this year."

To prepare for a widespread flu outbreak, consider the following:

  • Redesign triage.

At Northwest Community Hospital in Arlington Heights, IL, nurses originally had planned to create a separate "flu unit" by relocating oncology patients, but this turned out to be a poor plan, says Rosemary Kucewicz, RN, BSN, ED manager. "Our VP of nursing thought that was a bad idea because that unit has all private rooms and we would not be able to cohort flu patients," she explains.

Instead, supply storage space will be relocated so that rapid influenza testing can be done at triage. "We want to be able to do flu swabs there and send specimens directly to the lab from triage," says Kucewicz.

At Northeast’s ED, an office was relocated to create additional triage space. "Already this year, there have been times that we have used the third triage bay and needed a fourth one," says Walter.

  • Implement disaster procedures.

During the previous flu season, Children’s Healthcare of Atlanta’s two EDs were operating at 200% of capacity, seeing an additional 3,000 patients a month compared to previous years, reports Linda Cole, RN, vice president of emergent services. "Our volumes were off the charts," she says.

For this disaster, the hospital was forced to implement emergency command procedures, says Cole. "You usually think of a disaster as a bus wreck or tornado, but it’s really any time when the ED lacks adequate resources," says Cole.

Staff from finance, facility management, and inpatient nursing helped out in the ED with patient transport, paperwork, and customer service in waiting areas. "The only way we got through it was for the hospital to pull together as a team and not look at it like an ED problem," she says. "It may have started in the ED, but it very quickly became an issue for the entire hospital."

  • Create a space for overflow patients.

When flu volumes rise dramatically, lack of space becomes a problem, including inpatient beds, ED beds, and even waiting space. "We had people waiting in very unusual places, such as the hospital lobby, because there was no physical space in our waiting room," says Cole. To address this, a four-bed day surgery area is used to hold ED patients during evening hours, and patients are moved to the ED’s fast track during the day, she says.

At Northeast’s ED, when more than 25 patients are waiting, a nine-bed outpatient area is used, staffed by an on-call ED nurse and technician, says Walter.

  • Add technicians at triage.

Two additional ED technicians will be added at triage during peak volumes, says Walter. "One of the techs would be responsible for taking vital signs on patients upon arrival," she says. "This will hopefully prevent the person who is 17th in line from waiting with a blood pressure of 60 mmHg."

The second technician will perform flu testing, send the test to the lab, and be on the lookout for results to notify the lead triage nurse, says Walter.

  • Expedite discharge of ED patients.

If Northeast’s ED is inundated with flu patients, the hospital’s nursing supervisor is immediately notified to evaluate the entire hospital for alternatives, Walter says. "They have the big picture of what is going on throughout the hospital and can facilitate getting patients out of the ED and into an inpatient bed."

Here are some of the possible interventions:

— Calling on staff throughout the hospital to transport patients out of the ED, such as radiology transporters to bring stable patients to their assigned bed, and receiving units to come to the ED to transport their patients.

— Opening up discharge holding areas for patients awaiting rides home.

"This would allow housekeeping to proceed with cleaning the room and making it available for an ED patient," says Walter.


For more information on how EDs are preparing for the flu season, contact:

  • Linda Cole, RN, Vice President of Emergent Services, Children’s Healthcare of Atlanta, 975 Johnson Ferry Road, Suite 550, Atlanta, GA 30342. Telephone: (404) 785-2080. Fax: (404) 785-2081. E-mail:
  • Rosemary Kucewicz, RN, BSN, Manager, Emergency Department, Northwest Community Hospital, 800 W. Central Arlington Heights, IL 60187. Telephone: (847) 618-4010. E-mail:
  • Sherry Walter, RN, MSN, CCRN, Clinical Director, Emergency Care Center, Northeast Medical Center, 920 Church St. N., Concord, NC 28025. Telephone: (704) 783-1648. Fax: (704) 783-2384. E-mail:

FluSurge is a free spreadsheet-based model that estimates the surge in demand for hospital-based services during influenza pandemics. To download, go to:, and under "References and Resources," click on "Pandemic Preparedness," and then "FluSurge (software and manual)." For more information about FluSurge, contact Martin Meltzer, PhD, Centers for Disease Control and Prevention, NCID/OD/OS, Mailstop C-12, 1600 Clifton Road, Atlanta, GA 30333. E-mail:

A Pandemic Influenza Response and Preparedness Plan with recommendations to facilitate response and recovery during and after an influenza pandemic can be downloaded at no charge at the Department of Health and Human Services web site ( Click on "Core Document."