Flu vaccine shortage places premium on infection control and surge capacity

ACEP recommends ban on boarding, calls it a highly dangerous’ practice

With the flu season upon us and only half the normal supply of vaccine available, ED managers are preparing and bracing for a greater influx of flu patients this year. Experts agree their primary focus should be in two areas: infection control, which includes optimal use of available vaccine and encouraging staff and patients to practice good preventive hygiene; and more effective, efficient handling of patients.

"We are deeply concerned about what will happen if tens or even hundreds of thousands of severely ill flu patients surge into already crowded emergency departments this winter," says Arthur L. Kellermann, MD, MPH, professor and chair of the department of emergency medicine at Emory School of Medicine in Atlanta and a member of the board of directors of the American College of Emergency Physicians (ACEP) in Irving, TX. Also, if too many frontline health care workers fall ill with the flu, there won’t be enough left to adequately staff the nation’s ambulance services, EDs, trauma centers, and intensive care units (ICUs), he adds.

"Either development could lead to a catastrophic failure of our emergency care system," Kellermann says.

That’s why on Oct. 18, ACEP issued an urgent call for an immediate crisis summit of government and private-sector organizations to make contingency plans for the coming flu season, Kellermann says. He cites these ACEP recommendations to avert the threat:

  • Immediate, targeted vaccination of vital frontline health care workers, including paramedics, emergency physicians and nurses, and ICU personnel.
  • An immediate ban on boarding admitted patients in ED hallways. Troubling in the best of times, this practice is highly dangerous during an epidemic of contagious disease, according to the statement from ACEP.
  • Immediate adoption of regional protocols to monitor hospital capacity and fairly distribute ambulance patients.
  • Contingency plans to force hospitals to free up inpatient beds by postponing or canceling elective admissions if their community is severely hit by the flu.
  • Creation of a reserve fund to compensate cash-strapped hospitals for the extraordinary costs of complying with these measures.

Beyond the vaccination of as many frontline workers as possible, there are several additional steps you can take to limit the spread of influenza. For example, most hospitals now are practicing Universal Respiratory Etiquette, first introduced by the Centers for Disease Control and Prevention (CDC) in response to the severe acute respiratory syndrome (SARS) outbreak of recent years, sources say. (For more information, see resources, below.)

In addition, the CDC has issued guidelines concerning which staff should receive top priority when it comes to inoculation. (The complete guidelines are available at www.cdc.gov/flu. On the left hand side of the page, under "For Health Professionals," click on "infection control." Next, click "Infection Control Measures for Preventing and Controlling Influenza Transmission in Health Care Facilities.")

There are several other key steps you can take, adds Darlene Bradley, RN, PhDC, MSN, MAON, director of emergency and trauma services at University of California, Irvine (UCI) Medical Center and president of the California chapter of the Emergency Nurses Association (ENA). "Early education [of patients] will prevent a lot of these people from overburdening the system," she says. "Our goal is to focus on prevention and education, so people do not use us as a primary source of care."

On her hospital’s web site (www.ucihealth.com), there is information posted for the public, including a link to the CDC web site for flu care at work, home, and school. (See "Click here for information from the CDC on the flu and flu prevention.") The hospital web site also describes many monthly community events, including a current program titled "Ask the Doctor: Flu Shots and Other Immunizations."

"We also have a newsletter [The Flu and You] that goes out to area citizens," Bradley says. (The newsletter, available at www.ucihealth.com/News/UCI%20Health/fluandyou.htm, addresses questions such as: Is it flu or just a simple cold? and Do I need to go to the emergency department?)

The education process continues inside the hospital. "In our entrance, there is signage that says: If you have a cough, are sneezing, or have a fever, go to the desk.’ There they have waterless hand washing available; and if their disease looks airborne, they get a mask and then are cohorted into a special triage room with negative airflow."

In cohorting patients, families are put together in one room. "Also, we have two parts of the ED," says Bradley. "The first part is pretty open; the second has private rooms with doors at each section of the hallway. Our goal is to cohort the patients [in the private rooms] so the spread of infection is limited to those areas."

Every discharged patient will be given guidelines for flu care, "so they can take care of themselves and their family, without bringing them back to the ED," she adds.

In the back of the ED, housekeeping will be cleaning constantly to remove any droplets or anything else that may have come in contact with sick patients and/ or could spread infection.

In addition, Bradley says, everything is being done to make sure staff washes their hands frequently. "We have soap and water hand-washing stations, as well as waterless soap everywhere," she notes.

When it comes to surge capacity, "I look at it as a river with a dam and a storm coming in," says Elaine Nelson, MD, FACEP, medical director of the emergency departments at sister hospitals San Jose (CA) Medical Center and Regional Medical Center of San Jose. "So the questions I ask are: How big is the capacity of your lake? How quickly will water be coming in? How quickly can you be letting water out?"

In terms of the ED, she says, those questions mean how many patients are arriving, how many can you take care of at once in the ED, and how quickly are patients exiting the ED?

As San Jose Medical Center will be closing soon, Nelson has more resources available to her to increase capacity at the sister hospital than the typical ED manager. She is increasing capacity at Regional Medical by five beds and also increasing nursing shifts by approximately 50%, as well as increasing the number of physicians and physician assistants (PAs) by approximately 75%.

"We are also going to immediate bedding," she notes. "If there is an available bed, the patient goes there immediately without stopping at triage. We have the patient see a care provider immediately." If no bed is available, there will always be a physician or a PA available in triage. This practice was put into effect in late October.

"We will treat and discharge if it is a minor problem, or get orders started like labs and X-rays," says Nelson. "This should help expedite throughput once a bed is available."

Nelson also instituted a hospitalist program on Nov. 1. Available 24/7, the hospitalists "are completely dedicated to moving patients safely through," she says. "When they have patients, rather than finish off at the clinic, they are immediately available to start the admission process and to work with inpatient units to expedite tests that could potentially slow down admission."

Finally, Regional Medical opened an urgent care clinic next to the ED Dec. 1, 2003. "We hope some of the patients with minor illnesses or injuries will self-select to present there, which will lighten the load for our ED," Nelson adds.


For more information on strategies to deal with the flu vaccine shortage, contact:

  • Darlene Bradley, RN, PhDC, MSN, MAON, Director, Emergency and Trauma Services, University of California, Irvine. Phone: (714) 456-5248. E-mail: dbradley@uci.edu.
  • Arthur L. Kellermann, MD, MPH, Professor and Chair, Department of Emergency Medicine, Emory School of Medicine, Atlanta. Phone: (404) 778-2600. E-mail: Akell01@emory.edu.
  • Elaine Nelson, MD, FACEP, Medical Director, Emergency Departments, San Jose Medical Center and Regional Medical Center of San Jose, San Jose, CA. Phone: (408) 928-7019. E-mail: nelson_elaine@hotmail.com.

For more information on Universal Respiratory Etiquette, see, 2003 DRAFT Guidelines for SARS, available free at www.cdc.gov. In the "search" box, type in "Universal Respiratory Etiquette." The Universal Respiratory Etiquette is described on pages 9 and 10 of "Supplement C: Preparedness and Response in Healthcare Facilities."

For information on Universal Respiratory Etiquette, see:

  • Lenehan GP. Universal respiratory etiquette: A modest proposal. J Emerg Nurs 2004; 30:3.