EDs brace for high volumes and acuity due to flu vaccine shortage

Take steps now to bolster staffing and prevent transmission in waiting areas

Although ED nurses at Towson, MD-based St. Joseph Medical Center had treated two flu-related cases as of press time, neither patient had the flu.

"Both patients were elderly and had waited hours on line to get a flu shot," says Vicki Blucher, RN, BSN, CEN, clinical educator for the ED. One patient passed out while waiting and was admitted to the hospital, while the other complained of weakness.

The story underscores what most ED nurses are anticipating: Due to a shortage of the flu vaccine, this flu season is going to be anything but ordinary. "We anticipate an increase in volume and also acuity," says Susan McAllen, RN, BSN, CEN, administrative nurse manager for the adult and pediatric EDs at Montefiore Medical Center in the Bronx. "Even though high-risk patients are supposed to be getting the vaccine, we know that certain people are not going to be able to obtain it for whatever reason."

Nina M. Fielden, MSN, RN, CEN, clinical nurse specialist for the ED at Cleveland Clinic Foundation, says, "I am worried about the nursing home patients who aren’t getting vaccinated, and then a mini-epidemic breaks out."

Because of concerns about the vaccine shortage, ED staff at Palomar Pomerado Health in Escondido, CA, held a press conference educating the public on the importance of hand washing and keeping the elderly and the very young away from others known to have the flu, reports Kim Colonnelli, RN, BSN, MA, district director for emergency and trauma services.

Nurses point to the 2003-2004 flu season, which had an unusually early onset and killed 152 children, as reason for concern, along with constant news reports about the vaccine shortage inflaming public worries.

"We are concerned that this is getting so much media attention that patients with upper respiratory illnesses may seek ED care because they are concerned they have the flu," says Rosemary Kucewicz, RN, BSN, ED manager at Northwest Community Hospital in Arlington Heights, IL.

To reduce transmission of the flu and avoid staffing shortages, consider these steps being taken by several EDs:

  • Encourage ED staff to get the flu shot immediately.

At most EDs interviewed by ED Nursing, limited doses of the flu shot were being offered to staff.

"Every effort will be made to give them the [inactivated flu shot] vaccine itself, but we were also able to secure almost 500 doses of the FluMist, so people will be able to get that instead if it’s not contraindicated," says Blucher. FluMist is an intranasal influenza vaccine manufactured by MedImmune in Gaithersburg, MD, and contraindications include individuals who are pregnant, have immune deficiency diseases, or a history of Gullain-Barre syndrome. (For more information about contraindications, go to www.flumist.com. Click on "Health Care Professionals" and "Prescribing Information.") Between the two types of vaccine, the entire ED staff will be covered, Blucher says.

Although the Centers for Disease Control and Prevention (CDC) does not recommend FluMist for health care workers who are in contact with severely immunosuppressed patients in protective care such as isolation units with positive air pressure, those who have contact with patients with lesser degrees of immunosuppression, such as diabetes, asthmatics taking corticosteroids, or HIV-positive patients, can get FluMist. (For more information, go to: www.cdc.gov/flu/about/qa/nasalspray.htm.)

In previous years, only about 30% of ED staff were vaccinated, says Kucewicz. "Prior to the shortage, we were going to make it mandatory this year," she adds.

There is enough vaccine to immunize every direct caregiver in the ED, but if the ED staff do not take advantage of it, then employee health will begin immunizing other direct caregivers in the hospital, says Kucewicz. "We hope ED staff will avail themselves of this opportunity," she says.

At Montefiore, the vaccine was prioritized for high-risk areas with direct patient contact including the ED, with about 70% of ED staff already vaccinated, says McAllen. "We’ve been very diligent in getting the staff vaccinated," she says. "If we end up being sick, there will be staffing shortages, and we need to be able to take care of the patients when they come in."

If a widespread flu outbreak occurs, ED staff will be offered a 30-day supply of the prophylactic antiviral drug amantadine free of charge, says Blucher.

  • Prevent transmission in waiting areas.

Asking patients with respiratory symptoms to put on masks has become routine in many EDs. "This is the second year we are doing it, and we had no complaints last year," Blucher says. "It’s giving people increased awareness of infection control."

Additional waterless hand hygiene containers were added to waiting areas at Northwest’s ED, and respiratory packets containing tissues and a mask are offered at the ED entrance. "We are shouting from the rooftop, Hand washing, hand washing, hand washing!’" says Kucewicz.

In addition to alcohol gel hand washing dispensers and masks in ED waiting rooms, signs are posted at entrances asking visitors to refrain from visiting patients if they have flulike symptoms, reports Colonnelli.

ED nurses at St. Joseph’s Hospital and Medical Center will be screening suspected patients for influenza at triage and performing rapid diagnostic testing on lower-acuity patients who potentially could be discharged from the waiting room, reports Kim Flanders, RN, BSN, CEN, clinical nurse manager for emergency services. In addition, all patients with respiratory complaints or symptoms wear masks, as well as the triage staff when caring for these patients, she says. "Signs are posted throughout the department, and masks are available to the public at entrance doors," says Flanders.

Hand washing remains the best means to prevent transmission of the flu, she underscores. "Our hospital monitors and reports hand washing compliance quarterly by department," she says.

Cleveland Clinic Foundation is reinstituting a "cough respiratory etiquette" that it started last year, says Fielden. "We are not emphasizing fever so much this year, as we did last year for SARS [severe acute respiratory syndrome], but are instead emphasizing cough," she says. Surgical masks, boxes of tissues, and hand sanitizer for patients are kept in waiting areas, and signs ask patients to notify nurses if they have a cough.

The signs show a person coughing and a picture of a surgical mask, and include instructions to cover the mouth; use tissues when coughing, sneezing, and blowing the nose; and clean hands afterward, says Fielden. "I will also be posting signs from the CDC that talk about other ways to avoid the flu," she says. (To obtain flu-related patient education resources, see below.)

  • Consider staffing in advance.

Palomar Pomerado Health is staffing up both EDs in anticipation of an influx of patients similar to what they had last year, reports Colonnelli.

At Northwest, nurses are discussing the possibility of creating a "flu unit" to care for these patients if volumes rise, says Kucewitz. "This would help the ED because there would not be as many blocked beds on the med/surg units," she explains. "However, this idea is not the top choice for the inpatient nurses because of the protective equipment you need to wear all day when caring for these patients."

The EDs at Palomar and Pomerado are working with the state department of health to establish guidelines for times when the capacity exceeds what the hospital can safely handle, with the goal of placing flu patients in nonclinical areas on a temporary basis.

"This might include a place that has otherwise been used as a meeting room, or a classroom," says Colonnelli.


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

  • Vicki Blucher, RN, BSN, CEN, Clinical Educator, Emergency Department, St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204. Telephone: (410) 337-1524. Fax: (410) 337-1118. E-mail: vickiblucher@chi-east.org.
  • Kim Colonnelli, RN, BSN, MA, District Director for Emergency and Trauma Services, Palomar Pomerado Health, 555 E. Valley Parkway, Escondido, CA 92025. Telephone: (760) 739-3320. Fax: (760) 739-3121. E-mail: kace@pph.org.
  • Nina M. Fielden, MSN, RN, CEN, Clinical Nurse Specialist, Emergency Department, Cleveland Clinic Foundation, 9500 Euclid Ave., E19, Cleveland, OH 44195. Telephone: (216) 444-0153. Fax: (216) 444-9734. E-mail: fielden@ccf.org.
  • Kim Flanders, RN, BSN, CEN, Clinical Nurse Manager, Emergency Services, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. Telephone: (602) 406-5147. E-mail: k3ander@chw.edu.
  • Rosemary Kucewicz, RN, BSN, Manager, Emergency Department, Northwest Community Hospital, 800 W. Central Arlington Heights, IL 60187. Telephone: (847) 618-4010. E-mail: rkucewicz@nch.org.
  • Susan McAllen, RN, BSN, CEN, Administrative Nurse Manager, Emergency Department, Montefiore Medical Center, 111 E. 210th St., Bronx, NY 10467. E-mail: smcallen@montefiore.org.
  • A variety of free downloadable patient education materials, including "Cover Your Cough" posters, brochures, and fact sheets are available on the Centers for Disease Control and Prevention web site (www.cdc.gov/flu/). Under "Health Professionals," click on "Patient and Provider Education."