Storm warning: ICPs prepare for influenza-swamped EDs

Facing potential public health disaster’

Infection control professionals are rolling out their severe acute respiratory syndrome (SARS) plans and steeling themselves for overwhelmed emergency departments (ED) after the nation’s leading ED clinicians warned that a perfect storm may be forming this influenza season.

"Events are coming together that could predict a catastrophic health care disaster in the upcoming flu season," said J. Brian Hancock, MD, immediate past president of the American College of Emergency Physicians (ACEP). "We have inadequate numbers of vaccinations for our patients; and we have an overburdened, overstressed, and underfunded emergency health care system."

With about half the nation’s flu supply missing this year, the fear is EDs will be inundated as influenza strikes communities. The possibility of overwhelmed EDs previously was raised during the emergence of SARS, and accordingly, ICPs are turning to plans formed in response to that respiratory infection.

This year, a principal concern is that healthy adults and children who would have been immunized in a typical flu season will acquire influenza and seek emergency care.

"We’re anticipating a lot of young and middle-age adults, and children in middle school and high school," said Patti Grant, RN, BSN, MS, CIC, infection control director at RHD Memorial Medical Center in Dallas. "We may lose some of the herd immunity effect. That is our big concern. So we pulled up the SARS protocol for respiratory etiquette, and we expanded it to anybody who has a fever and a cough."

Developed by the Centers for Disease Control and Prevention (CDC) in response to SARS, the protocol calls for personnel to query patients about respiratory symptoms and to look for symptoms in patients and visitors. Because flu and SARS primarily spread via respiratory droplets, instruct people with symptoms of a respiratory infection to cover their nose and mouth with a tissue when coughing or sneezing. In addition, make hand hygiene products and tissues available in waiting areas and offer masks to symptomatic patients.

"There is signage posted all over the ED, and the nurses will triage them as they come in," says Grant. "We have the alcohol hand rubs and tissues throughout the waiting room and surgical masks for those who have a fever and are coughing. This is all done with explanation from the staff. It is more of an educational push than I have done in previous years because I can’t rely on the vaccine as much as I used to."

While Grant received adequate vaccine to immunize her patient care staff, ED clinicians say many in their critical ranks still are not vaccinated. ACEP is urging government officials to ensure that emergency care and critical care providers (EMS, nurses, physicians, and ancillary staff involved in direct patient care) are immunized so they aren’t stricken in the midst of a national epidemic. The group also is calling for a national crisis summit on flu to crystallize concerns and develop strategies for EDs.

"It makes no sense to have ill health care providers passing influenza to otherwise well patients," Hancock added.

Speaking at a press conference at the recent ACEP meeting in San Francisco, he lamented that there were not stocks of vaccine available to immunize the thousands of ED clinicians at the meeting. "My parents in the Chicago can’t get the vaccine, and we have an inadequate supply of vaccine to provide to the emergency physicians who are here. [This was] an absolutely phenomenal opportunity to vaccinate a significant portion of an at-risk group."

The beleaguered CDC is well aware of such concerns, but reminds that vaccine is being distributed on a staggered basis. "There are reports coming in from all sectors that people have not received their vaccine in various practice and clinic settings," said Scott Harper, MD, medical epidemiologist in the CDC influenza branch. "I have not heard about health care workers specifically, but I would be hard pressed to believe there are not health care workers out there who have had trouble getting it so far."

But again, vaccine availability is not an all-or-nothing proposition, he told Hospital Infection Control. "Several million doses every week are coming out and being distributed," Harper noted. "I think a lot of people have this idea that there is big supply of vaccine that is already out there and if they go somewhere and it’s not there, they are not going to be able to get it. In fact, it is continuing to be distributed over the coming weeks. We are trying to get the message out that if you don’t find it today that doesn’t mean it is not going to be there tomorrow."

Crystal ball says . . .

Of course, how bad the flu season will be is anyone’s guess. The early signs tracked by the CDC indicate that as of Oct. 28, 2004, 17 states were detecting sporadic flu activity (Alaska, California, Colorado, Connecticut, Florida, Idaho, Indiana, Michigan, Minnesota, Montana, Nevada, New York, North Dakota, Rhode Island, Tennessee, Texas, and Wisconsin). Some of the circulating virus is last year’s nemesis, the influenza A (H3N2) Fujian strain. However, that strain now is covered in this year’s vaccine — if you can get it.

"It’s still real early so it’s hard for anyone to predict with confidence the magnitude of this year’s epidemic," said Arthur Kellermann, MD, chairman of the department of emergency medicine at Emory University School of Medicine in Atlanta. "But if you look at the early sporadic cases that are coming in, the good news is the H3N2 strain is in this year’s vaccine. The bad news is that the H3N2 strain tends to cause more severe influenza then the dominant strain last year."

Adding intrigue to the situation is the global emergence of the so-called "Wellington" influenza A strain, which was named after the New Zealand city where it first appeared.

The strain is not included in the current U.S. vaccine, but the World Health Organization already has recommended that it be included in next year’s vaccine for the Southern Hemisphere. The Wellington strain reportedly has made its way to Northern Europe, but as this issue went to press, had not been reported in the United States. Regardless, the current scenario is sufficiently dire without throwing in that "X" factor.

"Depending on who you ask, between 85 million and 180 million Americans fit one or more of the CDC’s criteria for high-risk individuals either based on age, underlying health status, immune-compromised, or because they are a critical frontline health care provider," Kellerman said at the ACIP press conference. "The nation has only 55 million doses of vaccine. You do the math."

In an average flu season, the influenza puts 200,000 Americans in the hospital and kills 36,000. It would come as little surprise if those numbers increased this season in the absence of sufficient vaccine.

"Although it is impossible to predict, this flu season will likely be much worse than a usual flu season because of the shortage of vaccine," said Kellerman. "If that happens, the number of flu victims who will need emergency care and hospitalization will be substantially greater then in recent years. Now this begs an important question and one that I haven’t seen anyone in the press and anyone in the government address to this point: Where will these patients go?’"

Unfortunately — for ICPs looking at existing overcrowding in their hospital EDs — many of the influenza infected may be coming through the ED doors. "The majority of America’s emergency departments are already packed with patients," Kellerman said. "ER crowding is a nationwide problem affecting private hospitals and public hospitals alike. America’s emergency physicians and nurses are quite capable, but we cannot provide good care when every exam room, hallway, and broom closet is packed with patients."

Not just flu patients will be affected

According to ACEP, the nation needs long-term answers including government funding to prevent the ongoing closure of hospitals and EDs. In addition, hospitals have to stop the practice of boarding admitted patients in EDs for hours and even days. Despite 40 million uninsured nationally, recent studies show that EDs actually are used more often as a safety net for those with insurance, according to data presented at the ACEP meeting. However, reimbursement is insufficient to make the arrangement a fiscal winner for hospitals.

In any case, the problem of chronic ED crowding is multifactorial, and includes business decisions such as holding back available beds for adequately insured patients coming in for elective surgery.

"Hospitals are functioning on very small margins," said Robert Sutter, MD, ACEP president. "They are barely getting by, and the way that they are getting by is by prioritizing patients with elective admissions and problems that they can make their budget on. But unfortunately, in this situation, [epidemic flu], the elected admissions have to stop. A hospital facing financial issues every day will not easily or readily do that."

Indeed, communities that already have insufficient emergency care capacity due to hospital closings may have to declare a public health emergency if they are beset with epidemic influenza.

"[Those communities would] have to look seriously at declaring a public health emergency very early in the flu season to put a grinding halt — to the greatest extent possible — to the transmission before you get to that tipping point where you have an epidemic that is affecting and overwhelming the entire community," Sutter said at the ACEP press conference.

"A public health emergency would give the local government and public health authorities the power to implement many of our suggestions and many of other measures that may not be voluntarily adopted," he noted.

Of course, the rippling effect of a flu-burdened ED is that those seeking care for other maladies may be left in a lurch.

"ED crowding delays treatment and increases risk of medical errors, frustrates patients and burns out staff," Kellerman said.

"It also promotes the spread of disease. When patients are packed together the risk that germs will be transmitted to another is dramatically increased. In light of the critical shortage of vaccine and the ongoing crisis of ED crowding, [we] are faced with a prospect of a perfect storm — an impending surge of critically ill flu patients and inadequate resources to care for them. Unless urgent steps are taken now, my colleagues and I believe that our nation faces the potential for a public health disaster this winter."