ER physicians fear possible fall flood of flu

Sep 9, 2009 (CIDRAP News) – As children return to school and promptly become infected with H1N1 influenza, emergency-room (ER) physicians nationwide are becoming increasingly anxious over their ERs' capacity to deal with an influx of flu patients.

Many of the physicians work in emergency departments that experienced a spring onslaught of flu and fever cases when H1N1 first struck. In some cities, those cases were part of an early wave that receded; in others, the count of flu cases climbed and has kept climbing through summer months that usually are flu-free.

In either situation, the physicians say they are concerned that the expected fall increase in H1N1 flu—plus the annual arrival of seasonal flu—will significantly perturb a system that has little capacity to handle excess demand. And if H1N1 flu undergoes enough mutation or reassortment to add significant virulence to its notable contagiousness, they add, chaos could result.

Potential for a perfect storm
"From what I have been reading, the flu season in the Southern Hemisphere has been very, very bad—they have been swamped with an increasing number of cases," said Dr. Stuart Bradin, an assistant professor of pediatrics and emergency medicine in the

University of Michigan Health System. "So I think we are in quite a bit of danger of having a very bad flu season here. Having seasonal flu on top of that, and considering that the pandemic flu strain may become more virulent than its initial presentation, I think is the potential for a perfect storm."

Some physicians have been hearing early rumbles of that storm since H1N1 appeared in late April.

"The months of May, June, and July were 3 of our top 6 months ever, in terms of emergency department volume, going back at least 10 years," said Dr. Brian Zink, chair of emergency medicine at Warren Alpert Medical School at Brown University in Rhode Island.

Dr. David Munter, emergency department director at Sentara Obici Hospital in Suffolk, Va., said: "I have never before, in a 28-year career, seen flu in June, July, and August, but we had it, and it was all in teens and young adults. We had no summer dip [in cases] at all."

He added: "I think when school starts, it will explode."

The physicians say that many of the flu patients they saw and expect to see are not gravely ill. Some, especially in the spring, were worried well seeking tests or reassurance. Most who came for care over the summer had fever and other flu-like symptoms, but did not need to be admitted to the hospital and were discharged to recover at home.

The spring wave of cases "increased our wait times and reduced efficiencies," Zink said. "Individuals who needed to be wearing masks, we had to stop and get masked in triage, so it slowed the triage process down. And we went into rooms masked and using contact precautions, which adds a little bit of time to each encounter. But we see 100,000 patients a year in our main hospital [ER], so if you add even a few minutes to each patient, it slows everything down."

ERs already under stress
H1N1 arrives at a time when emergency medicine nationwide is widely considered "at the breaking point"—the title of a 2006 Institute of Medicine report on the precarious state of emergency care. That report estimated that ER visits rose by 26% between 1992 and 2003, from 89.8 million to 114 million in a year, while 425 emergency departments and 703 hospitals closed and the number of hospital beds in use shrank by 198,000.

In April of this year, the American Hospital Association updated that calculation in a report that found 50% of 1,078 hospitals were treating more uninsured patients in their ERs, while approximately 10 hospitals per month were laying off 50 staff or more.

Meanwhile, the President's Council of Advisors on Science and Technology estimated in August that H1N1 flu may infect 30% to 50% of the U.S. population this coming winter, leading to as many as 1.8 million hospital admissions that could include 300,000 patients requiring placement in an intensive care unit (ICU). From 30,000 to 90,000 Americans could die, the report said, up to three times as many as die from flu in a normal year.

H1N1's progress through the Southern Hemisphere flu season appears to prefigure that. Last week, Dr. Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), acknowledged that Southern Hemisphere hospitals "had challenges to keep up with the number of people coming in" even though there was "no increase in the level of severity, no increase in the death rate."

Medicine's concern for H1N1's potential impact on ERs is so acute that the American College of Emergency Physicians, emergency medicine's specialty society, in July issued a "National Strategic Plan for Emergency Department Management and Outbreaks of Novel H1N1 Influenza." The plan, written under contract to the Department of Health and Human Services, walks ER directors through a potential H1N1 scenario, lists vulnerabilities that may prove to be weak points, and compiles 27 essential capabilities that ERs must fulfill to handle significant new demand.

Physicians preparing for the fall say uncertainty is a key element in their anxiety. On one hand, H1N1 flu and seasonal flu could cause mostly minor illnesses—but if those mildly ill patients come to ERs, they will take time to interview, assess, and treat, and take staff attention and bed space that might otherwise be devoted to the seriously ill.

That is likely to increase ERs' "length of stay," one key measure of how smoothly an emergency department is functioning. And while they are there, those patients may pose an infection risk to any other patients around them, who may be chronically ill or suffering from any of the underlying conditions that have been implicated in H1N1 deaths to date.

If on the other hand the two flus begin to cause very serious illnesses, they could significantly increase hospital and especially ICU admissions. Such patients might bypass an emergency department or stop in it only briefly, but they could nevertheless have a profound effect on its operations. That is because "boarding," or holding admitted patients in an ER until a bed opens up elsewhere in the hospital—another key measure of ER quality—is created when ICU and ward beds are full.

In a 2006 analysis, the Center for Biosecurity at the University of Pittsburgh Medical Center estimated that responding to a severe pandemic would require 4.6 times as many ICU beds and twice as many hospital beds as exist in the United States.

Strategies for preventing overload
Around the country, emergency departments and the hospitals that house them are crafting solutions that they hope will head off an ER overload. Many are considering creating satellite triage stations located away from ERs—in hospital parking lots, repurposed clinics, or even drive-throughs—all of which rely on keeping flu patients out of the ER and bringing healthcare personnel out to meet them.

Children's Healthcare of Atlanta, which operates three hospitals, recently placed on its website an interactive decision tool that allows parents to assess the severity of a child's symptoms so that only children who need emergency care will be brought to its ERs.

In Virginia, Munter envisions physically dividing his hospital's waiting room into two zones; one, a flu zone, would feed into a pre-designated isolation area within the ER. And the quality-focused Institute for Healthcare Improvement (IHI) will shortly publish a monograph proposing that flu patients be separated more radically, by being steered into what physicians call a "pathway"—a multi-step protocol triggered by a particular set of signs and symptoms—that would not only put them in certain rooms but process them at different speeds depending on results of tests given in a particular rapid order.

Several emergency physicians said that what they fear most for the fall and winter is not an onslaught of flu, but a slow crawl up the epidemic curve. An onslaught, they argued, would be recognized as a crisis and would trigger a coordinated response in the same way a plane crash does. But a steady increase, though it might eventually reach disastrous proportions, would be perceived at any moment as ER business as usual: vastly overcrowded but not deserving outside response.

"Our fear is that it will hit hard enough to really disrupt emergency department operations, but not hard enough to engage crisis-management protocols," said Dr. Joseph "Jody" Crane, a co-author on the forthcoming IHI paper and business director of the Fredericksburg (Md.) Emergency Medical Alliance. "That could wreak havoc on the running of emergency departments."

See also:

2006 Institute of Medicine report: "Hospital-Based Emergency Care: at the Breaking Point"
http://www.iom.edu/CMS/3809/16107/35007.aspx

2009 American Hospital Association report "The Economic Crisis: The Toll on the Patients and Communities Hospitals Serve"
http://www.aha.org/aha/content/2009/pdf/090427econcrisisreport.pdf

American College of Emergency Physicians' "National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza"
http://www.acep.org/WorkArea/DownloadAsset.aspx?id=45781

Toner E, Waldhorn R, Maldin B, et al. Hospital preparedness for pandemic influenza. (Meeting Report) Biosecur Bioterror 2006;4(2):1–11 [Full text]

Childrens' Healthcare of Atlanta Interactive Flu Assessment Tool

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