Virulent influenza fills EDs across the country, prompting hospitals to launch emergency plans

Experts: Have surge capacity ready in case demand for care spikes

After a few mild seasons, the flu packed a wallop this year, straining resources in hospitals across the country and forcing some EDs to go on diversion during peak periods.

Particularly hard hit was Boston, MA, where the mayor declared a public health emergency in the second week of January. By January 13, Massachusetts General Hospital (MGH) reported that it had already identified 618 cases of flu and had admitted 196 patients.

"In addition to the large numbers of patients coming to the ED with flu-like illness, we have had members of our clinical staff (nurses, physicians, NPs, and PAs) fall ill, leading to staffing challenges in the midst of the increased volume," explains David Brown, MD, associate chief and vice chairman of the Department of Emergency Medicine at MGH. "In response to this, MGH has initiated its flu surge plan, in which primary care practices, both adult and pediatric, extend their hours into the evening and leave slots open during the day for ill patients seeking medical attention, in order to ease the burden on the ED."

In addition, Brown says the ED activated its own internal surge plan, which calls for an additional attending physician and PA to come in and work when the ED reaches threshold levels of crowding. "This occurred several times during the last week in December and the first few days of January," he adds. (Also see, "For debut this spring: A user-friendly tool to predict flu activity," below.)

Public health officials in New York State also declared a public health emergency as hospitals there were besieged by patients with symptoms of flu. In early January, Montefiore Medical Center in New York City noted that as many as 40% of the patients seeking care with symptoms of flu in the ED were testing positive for influenza, and the situation was similar in many other EDs. By January 10, more than 15,000 cases of flu had been reported across the state, nearly a three-fold increase in flu cases over 2012. And hospitalizations from the flu were up by 169%.

In Illinois, the flu emergency appeared to reach a peak on January 7, 2013. That's when at least 11 hospitals began diverting patients from their EDs because they were so overwhelmed with patients exhibiting flu-like symptoms.

Take steps to reduce wait times

Overall, the Centers for Disease Control and Prevention in Atlanta, GA, reported that the number of flu cases had more than doubled from last year, and that most states were seeing moderate to severe activity. While epidemiologists noted that this year's flu vaccine was roughly 60% effective against the virus, some noted that the flu strain largely responsible for the surge in patients this year was unusually aggressive. At the same time, they observed that EDs were also seeing a large number patients suffering from a new type of norovirus or stomach illness, which is also highly contagious.

While the halls of many large, urban EDs were filling up with flu patients, smaller community hospitals faced challenges as well. For example, after admitting more than 100 patients in a single week in early January, Lehigh Valley Hospital-Cedar Crest in Salisbury Township, PA, erected a surge tent in the hospital's parking lot to treat lower acuity patients.

Fairview Medical Center in Wyoming, MN, has been straining to meet high demand as well. The level III trauma center operates a conjoined ED and urgent care center, but since all patients go through the same triage point to determine where they should go for care, the surge in flu patients has been bogging things down.

"We have had to be creative in sending out a second triage person so that we don't have people waiting for extended periods of time," explains David Milbrandt, MD, the medical director of the ED at Fairview. "We are doubling and in some cases tripling our urgent care volumes. Our ED volumes are heavy also. They are a little over what they would normally be, but our urgent care volume is way above normal. And our admission rate is higher as well."

The surge in flu cases began at Fairview just before Christmas, prompting the hospital to implement its command center shortly after the holidays. Inpatient capacity and ICU capacity have both been stressed at times, explains Milbrandt. But he reiterates that most of the pressure was on the urgent care center.

"We added extra resources to facilitate taking care of these patients in a more timely fashion because we were getting to the point where there were four-hour waits in the urgent care center," he says.

Leverage non-clinical personnel

In addition, for the first time, the hospital administrators tried a new tactic: They leveraged personnel from non-clinical areas to help with patient surges. "What we found was our providers were getting sick as well, so we would have a lower number of people able to do the work," says Milbrandt.

Of course, non-clinical personnel couldn't perform medical tasks, but they did help out in other ways. "We had our environmental services people come in and help us turn over rooms. That is not typically their responsibility, but they were very willing to step in, realizing that everyone else was working really hard," explains Milbrandt.

People from nutrition also took steps to make sure the providers on duty had access to meals. Many of the physicians, nurses, and techs were so busy taking care of patients that they couldn't take breaks, so having food brought from the cafeteria down to their work site was very helpful, says Milbrandt.

"We also had some of our facilities personnel go out and help guide people to where they needed to go, so we tried to unload some of the workload from the ED staff, and the people who actually took on that work were really happy to do it," says Milbrandt. "It was some really good teamwork."

Should demand for care accelerate further, Fairview has plans in place to set up two flu clinics, one within the hospital and another at an outlying site in a heavily populated area.

The clinics would be used to take some of the pressure off the ED, primarily by handling the surge of lower-acuity patients. "There would be nurse-initiated protocols rather than having physicians have to man these centers," says Milbrandt.

One tool that has already proven useful this season is Zipnosis, a web-based service that connects people with minor medical issues with a clinician online. "People put in their complaints and, at the end of it, they will get a response from a provider within 30 minutes," observes Milbrandt. The service relies on established protocols to determine who would benefit from anti-viral medications like Tamiflu. For any serious symptoms, such as shortness of breath, for example, the patient will immediately be directed to go the ED.

"As we have tried to decrease the cost of care, there are some things that people don't need to physically show up for. And this creates another alternative way for people to receive care, especially during the flu season when you don't want a bunch of people sitting in the waiting room, infecting people who don't have the flu," says Milbrandt.

To limit such transmissions from taking place, ED staff have attempted to separate patients exhibiting flu symptoms from other patients in the waiting room, and they are providing them with masks, adds Milbrandt.

Keep the ED free for acutely ill patients

At press time, it was clear that not all areas of the country were experiencing the same kind of stress from flu as the Northeast and Midwest. At the University of Miami Hospital in Florida, for example, 4-5% of patients were presenting to the ED with flu-like illness, explains Robert Levine, MD, chief of the University of Miami School of Medicine's Division of Emergency Medicine and director of the ED at the University of Miami Hospital (UMH).

"I don't get the sense that we are being overwhelmed. In fact, we are not admitting a lot of these patients," says Levine. "The illness we are seeing is mild to moderate, not similar to the overwhelming flu we have sometimes seen in the past that results in lots of ICU admissions."

Levine has only been at University of Miami Hospital for a year, but he notes that he has witnessed flu seasons that were much more severe than the current one. "In Houston, where I used to work, we had some years where we would have a quarter or a third of the patients in the ICU on life-support who were flu victims," he says. "That's a lot of patients, and many of them had very life-threatening illness."

Levine cautions that the number of flu cases was still trending upward in the ED at UMH, but he says there is no need as of yet to implement emergency plans. "Our biggest challenge is that we ran out of swabs to test for flu, but that has not been a big encumbrance," he says. "We are just treating patients empirically as they are doing in the Northeast. If someone comes in with an influenza-like illness, we will just treat them."

While the length and severity of this year's flu season is not yet clear, Levine stresses that it is important for any ED to have mechanisms in place to quickly ramp up if patients complaining of flu begin to overwhelm the department. "You need to have a way to open up additional pods to see patients, and some clinics to direct patients to if the need arises," he observes. "And as far as inpatients go, we have had to sometimes expand our ability to take care of critically ill patients by opening up additional areas in the hospital."

It can also be helpful to dedicate one area of the ED to taking care of flu patients. "Then dedicate personnel to try to process these patients rapidly," he advises. "Depending on how sick the patients are, they can really overwhelm an ED, especially when the virus is particularly severe. When flu patients are really sick, it can take four to six hours to see them and get them stabilized."

During peak periods of demand, it is important to try to keep the ED free for those patients who are acutely ill, stresses Levine. "We tell staff, as well as patients, to stay home, drink plenty of fluids, and to try to see their private physician unless they are really sick," he says. "You can't be perfect, and our general tendency is to err on the side of telling people that if they feel ill and are worried, they should come to the ED. But people with no fever, who are able to eat and drink, can generally go to their family physician."

However, symptoms such as shortness of breath, feeling weak or dizzy, or high fever are red flags to tell the patient to come in right away, adds Levine.


David Brown, MD, Associate Chief and Vice Chairman, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. Phone: 617-726-5273.

Andrea Dugas, MD, Emergency Medicine Research Fellow, Johns Hopkins University, Baltimore, MD. E-mail:

Robert Levine, MD, Chief, Division of Emergency Medicine, University of Miami School of Medicine, and Director of the Emergency Department, University of Miami Hospital, Miami, FL. Phone: 305-689-5464.

David Milbrandt, MD, Medical Director, Emergency Department, Fairview Medical Center, Wyoming, MN. Phone: 651-982-7000.

For debut this spring: A user-friendly tool to predict flu activity

The early arrival and severity of this year's influenza season may have caught some ED administrators off guard, but it did not come as a surprise to Andrea Dugas, MD, an emergency medicine research fellow at Johns Hopkins University in Baltimore, MD. "I had suspicions that this was probably going to be a more severe influenza season just because of the cyclical nature of influenza," she says, pointing out that last year's flu season was "incredibly mild."

Another tip-off to the nature of this year's flu season came in September. That's when Dugas observed that flu activity began picking up on Google Flu Trends, an Internet-based tool that monitors search traffic for influenza. "That provided a clue that influenza season was coming early this year," she says.

Dugas has been consumed with such data for months as she and colleagues toil away on a predictive model intended to help hospital and ED administrators better anticipate the levels of staff and resources they will need to handle flu-related patient volume in future weeks. The work is funded by a grant from the Department of Homeland Security, but is being carried out by the National Center for the Study of Preparedness and Catastrophic Event Response (PACER), an independent center that works in conjunction with Johns Hopkins University.

While EDs already have plans in place to handle flu-related patient surges, experts say they don't have a great way to predict when, precisely, to launch these plans. What often happens as a result, they say, is severe crowding in the ED and long patient wait times during the height of flu season.

A tool is in the works

Early on in the quest to develop a better predictive method, researchers validated that Google Flu Trends did, in fact, present an accurate picture of current flu-related activity, at least on a city-wide basis. They then tested a number of predictive models to see how well the instruments could forecast future flu-related activity.

"The model that performed the best was actually an auto-regression that was based on the number of influenza cases seen in the ED," says Dugas. "You could watch the trend and see how the number of flu cases increased, and then use that information to predict what the next point was going to be."

This particular model performed even better when researchers added the Google Flu Trends data to it, explains Dugas, so the researchers have been fine-tuning an algorithm that crunches data regarding the number of flu cases seen over time with Google Flu Trends values for a particular location over time. "That gave us the best model, the most accurate model, to predict what was going to happen the following week in a particular ED," adds Dugas.

Currently, the researchers are in the process of validating the tool regionally to make sure that the predictive model will work across regions and throughout the United States. "In conjunction with that, we are also developing a tool for ED administrators and hospital planners to use," says Dugas.

It is going to be a free, Internet-based tool in which ED directors can log in, create an account, and enter their own hospital data pertaining to the number of flu cases seen per week over a period of time, explains Dugas. "The tool will then pull in the Google Flu Trends data [for the region], and in the background run this algorithm and predictive model, and just give them an idea of what to expect," she says. The tool will then store the data so that administrators can make use of it in subsequent flu seasons.

More trials planned

Given the virulent nature of the current flu season, Dugas wishes she could have had the tool up and running earlier. But at this point, she feels confident that hospital administrators will have access to the tool before next year's flu season begins to kick in. In fact, she is hoping to debut the website where the tool will be housed as early as this spring. "Then we are hoping to do some trials, get some feedback, and see if we can optimize this," she says.

Dugas isn't recommending that EDs act on information from the tool in isolation, but she does think it will be helpful as an additional weapon in their arsenals. "We are still experimenting and validating to make sure this will be accurate, but take a look at it and see if it helps with decision-making," she advises.