Fall flu wave tested pediatric hospitals with tough choices

Jan 5, 2010 (CIDRAP News) – In early August 2009, when the pandemic virus started tearing through southern states where schools had already started, the pandemic preparedness team at Children's Hospitals and Clinics of Minnesota felt a sense of foreboding that the virus was poised to strike the area a second time.

Pediatric hospitals throughout the United States have been at ground zero during both waves of the pandemic. The patients they care for are among the groups at highest risk for complications from the pandemic virus—young people with chronic health conditions such as asthma, diabetes, neuromuscular disorders, and forms of cancer.

Throughout the pandemic, communities have relied heavily on children's hospitals as high-profile sources of flu information. When the vaccine made its debut in October, public health officials took advantage of such hospitals' unique ability to reach many of the highest-risk groups with the first doses.

Gigi Chawla, MD, chief of staff at Children's, said the organization stepped up its flu outbreak procedures at the St. Paul and Minneapolis campuses about 3 years ago, after the area experienced a bad season with significant morbidity and mortality. When the first novel H1N1 cases were identified in Mexico and California in late April, she said hospital administrators anticipated a possible pandemic and put a strategic team in place, led by the director of infection prevention and the director of safety. By the third week of May, the hospitals faced a growing demand for information about the new flu, and both worried well and sick patients started streaming into the emergency departments, with the load spilling over to outpatient clinics.

Patsy Stinchfield, NP, director of infectious disease/immunology and infection prevention at Children's Hospitals and Clinics of Minnesota, is a veteran of many disease threats, including measles, SARS (severe acute respiratory syndrome), and smallpox, but she says pandemic flu stands apart. "There is nothing like this. There is such a need for information, and the information is changing so rapidly," she said.

After the spring flu wave died down, Children's Hospitals and Clinics of Minnesota conducted tabletop exercises to help test and tweak its pandemic response plan. David Hirschman, MD, medical co-director for the group's emergency departments in Minneapolis and St. Paul, said plans, triggers, and thresholds were established by the time the virus struck Minnesota again when schools reopened in early September.

Fall wave tested emergency department
Hirschman said the outbreak down south was 2 weeks ahead of what Minnesota would see. "We knew it was coming, and it did, in fact," he said, adding that the emergency department tracked flu activity on an hourly basis. "We're the thermometer for the community. We can tell you as soon as there's a change."

When the second wave hit, the emergency department was ready, Hirschman said. "We are accustomed to ebbs and flows with illnesses such as RSV (respiratory synctial virus) and seasonal influenza, but this was far outside of what we ever expected," he said.

During the peak in October, both the Minneapolis and St Paul emergency departments saw more than 200 patients a day—about 50% to 60% higher than usual for the month. The increasing patient load prompted the department to move a few notches up on its response system, but did not overwhelm it, Hirschman said. For a short time the outpatient surgical units postponed some procedures to create extra capacity for inpatients.

"This was a good test for our system, and we functioned well," Hirschman said, adding that the hospital didn't run short on ventilators or other key equipment. "But if the pandemic was severe, there is not a good pressure relief valve on the whole system," he said.

As October wound down, Minneapolis Children's Hospital was in the midst of an unusual situation—a transition to a new emergency department. The department now has 10 more patient rooms, with 16 more for overflow capacity. The new ED has four negative-pressure rooms, which will be useful if a third pandemic wave hits or another infectious disease threat surfaces.

Speeding vaccine to the most vulnerable
Chawla said that when flu activity first started picking up across the nation in the fall, it became clear that the vaccine supply would come later than expected, and in smaller quantities. The Children's Hospital system developed a plan to get vaccine to the most at-risk children and identified them through the outpatient clinics at both hospital campuses.

She said the system's information technology department helped pandemic response leaders identify all of the hospital and clinic patients, based on diagnostic codes, that were in the priority groups recommended by the US Centers for Disease Control and Prevention (CDC). "About 19,000 of our patients met the criteria, but we knew we wouldn't receive that amount of vaccine right away," Chawla said.

The hospital had to do its own risk stratification in each illness category, she said. For example, not every child with cerebral palsy was scheduled to get the very first vaccine doses, only the ones who couldn't manage their secretions. And they knew they wouldn't have enough vaccine early on to offer it to all kids with diabetes—only the ones who had glycosylated hemoglobin (HbA1c) levels greater than 10 with poorly controlled disease.

To make the tough decisions, the hospital used its in-house ethicist and brought in another ethics expert from outside, Chawla said. "We wanted to look at the issues as globally as we could."

In view of how much vaccine the hospital had, officials identified 6,000 of the highest-risk children, had their names electronically randomized, and used the resulting list to call their parents.If the hospital could reach a parent or guardian on the phone, they signed the child up for the first two vaccine clinics. If they couldn't get through on the phone, or if the adult declined, the hospital went on to the next name.

Watching children and their families stream into the first pandemic vaccine clinics on Halloween Day was a moving experience for many of the hospital employees who were involved in the event, she said. "Families were so desperate to have their children vaccinated. There was a large sense of pride, an emotional high."

The system received more vaccine by the third week of the campaign and was able to expand the priority criteria, Chawla said. By the fourth week, all of the high-risk groups could receive it.

Getting the vaccine to employees
Stinchfield said another challenge was ensuring that healthcare workers were protected from the new virus. She said the key was deploying doses right away and using a host of distribution strategies that were ready to go as soon as vaccine arrived.

"No one expected a dribble of vaccine. It was a low-flow garden hose, and now it's a regular garden hose. We all want the fire hose," she said. "The minute we got the vaccine, we used it."

Nurses put the first vaccine shipments it received on carts and went from unit to unit, vaccinating their colleagues starting with the departments at highest risk of exposure. When the supply increased, the system held 53 hours of mass-vaccination clinics involving 17 different sessions on four campuses, hitting all shifts. Officials also established a vaccine bases at each unit, along with an employee who was responsible for getting coworkers vaccinated.

Nurses and other healthcare team members who work in the neonatal intensive care units (NICUs) even came in on their day off to receive the vaccine as soon as their unit could receive it. "That’s the largest department, and getting 67% of their staff vaccinated in a single day—that speaks to leadership. The feeling was 'We are not going to have H1N1 come into our unit," Stinchfield said.

Though the hospitals already have a good track record for employee seasonal flu vaccination—last year they reached 80%—Stinchfield said she is proud of how willing employees were to get the pandemic vaccine. "That 60% of our patient care staff was vaccinated in one month with limited supply is unbelievable," she said.

Flu surge pressured many departments
The two flu waves, along with myriad unpredictable events linked to them, have affected nearly every department at Children's Hospitals of Minnesota, Stinchfield said. For example, she said shortages of pediatric suspension oseltamivir (Tamiflu) prompted the pharmacy staff to mix up "cauldron after cauldron" of compounded Tamiflu syrup.

The hospital supply department has managed unusual and challenging demands, she said. For example, in a typical October the hospital goes through 10,000 surgical masks, but during the second wave last October it used 160,000. Stinchfield said replenishing surgical masks hasn't been a problem, but maintaining a supply of N-95 respirators has been difficult. Though the hospital has enough to use during aerosol-generating procedures, no more are available from the manufacturer until next June.

The pandemic's impact on the infection prevention department, however, probably looms largest. "It has taken over my job. It's job 1—a big job 1 and an all-consuming job 1," she said. Along with the focus on the pandemic strain, she said the infection prevention team still has other duties every day, such as conducting surveillance for methicillin-resistant Staphylococcus aureus (MRSA), preventing bloodstream infections, and monitoring nosocomial infections.

Children's Hospitals put visitors' restrictions in place on Oct 1, launching a new method for screening visitors, she said. Each visitor receives one of three color-coded stickers to wear, based on the results of a brief health screening. For example, visitors who had any flulike symptoms were identified with a sticker and told to stay out of patient areas. Employees from many departments help watch to see if visitors are wearing their stickers and adhering to the tightened policies. "Visitor control has been critical, and there are a lot of layers of security committed to it," she said.

The hospital also works hard and has amended some of its policies to ensure that its own employees aren't coming to work sick. Though some hospitals stipulate that sick employees can come back to work after they're fever-free for 24 hours without the help of fever reducers, because of its pediatric patients most vulnerable to H1N1, Children's Hospitals asks sick employees to stay out for a week if they have an influenza-like illness. "It's a burden on employees, but the administration is allowing them to borrow forward on their PTO [paid time off]. And during a pandemic, people can donate PTO to their coworkers," Stinchfield said.

Pandemic flu sometimes put infection prevention interests in conflict with not only visitors' practices, but also the Child Life Department, whose job it is to make the environment nonthreatening to its young patients, Stinchfield said. Toys are absent from waiting rooms and other common areas because they can be a vehicle for spreading influenza. "It has been a balancing act," she said, adding that it has been helpful to have parental input on key committees.

Chawla said the demand for information has also placed unusual pressures on the health system's communications department, which has been issuing weekly updates, radio and television spots, and public service announcements about covering coughs, staying home when sick, and calling one's provider before coming to the emergency department. "When reporters called, we helped them educate the public," she said.

"Every department and group met and went above the challenge, and everyone does it with such a good heart," Chawla said. "It makes me feel really proud of the work that we do."

Looking back and ahead
Hirschman said an earlier emergency declaration from the Obama administration would have made it easier for emergency departments to change their care site, triage, and transport procedures quickly when the fall surge struck. The administration did not take the step until Oct 24, when the virus was already widespread in 46 states.

He said communicating with parents about when it's appropriate to bring children with suspected H1N1 infections in to the emergency department remains a tough challenge. And while the vaccine didn't arrive in time to blunt the second wave, it might help attenuate a third wave, if one develops

Stinchfield said the hospital will face clinical challenges over the remaining winter months, when other pediatric infections usually circulate, such as RSV, parainfluenza, streptococcus, rotavirus, and adenovirus.

"It's going to get complicated. We don’t want children to go untreated who need to be treated," she said. "Even if there's no wave, clinicians will keep H1N1 in the differential." The hospital will soon do its own reverse-transcriptase polymerase chain reaction (RT-PCR) testing for H1N1, which will help the healthcare teams distinguish among the different winter viruses and ensure that children get the right treatment, Stinchfield said.

Chawla said the hospital is continuing to see a slow, steady decline in pandemic H1N1 cases. "But we don't anticipate that this is the last we'll see of it," she added.

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