May 8, 2009 (CIDRAP News) – With the global outbreak of novel H1N1 influenza (swine flu) entering its fourth week, physicians at emergency rooms, clinics, and hospitals around the United States say they are overwhelmed with "worried well" who have as much as doubled their patient loads.

All the clinicians work at medical centers that have planned and practiced for pandemics and disasters. But the crisis has exposed a weak point that their preparation could not influence: a crush of fearful patients seeking reassurance, many of them sent to emergency rooms (ERs) for tests by workplaces, schools, and busy primary care physicians.

Those who have been dealing with the onslaught say it should serve as a warning. If this flu strain or another becomes more virulent—causing more serious disease than it now does, and presumably also inspiring more panic—the healthcare system will not be able to handle the demand.

"We are going to have to develop screening and triage systems that are not dependent on hospitals and emergency departments, or hospitals and emergency departments are going to be totally overwhelmed," said Dr. Edward Panacek, a professor of emergency medicine at University of California-Davis Medical Center, where ER volume has been running significantly above normal.

For several weeks, Panacek said, he has been seeing people with uncomplicated colds coming into the Davis Health System's ERs asking for flu tests, including "entire families with minimal to no symptoms," he said.

Panacek spoke just after returning from the annual gathering to administer oral exams for board certification in emergency medicine, a meeting that convenes physician-examiners from around the United States. No one took a scientifically based survey, he said, but almost every physician there reported increased ER traffic, including some late seasonal flu, almost no novel H1N1, and many worried well.

The same concerns are echoing through listservs used by pediatric emergency physicians, with many institutions seeing "50% to 75% increases," said Dr. Stuart Bradin, an assistant professor of pediatrics and emergency medicine at the University of Michigan Health System. At the university's main site in Ann Arbor, "there are definitely more parents who bring kids in for a cold or a low-grade temperature who might have stayed home or called their own primary care physician but are now coming in to 'make sure its not swine flu,'" he said by e-mail.

The stressed state of hospitals and ERs has been a persistent concern in pandemic planning since avian flu H5N1 began spreading across the planet 6 years ago. In 2006, the Center for Biosecurity at the University of Pittsburgh Medical Center estimated that, to handle a 1918-style pandemic, the United States would need twice as many non-intensive-care-unit (ICU) beds and ventilators and 4.6 times more ICU beds than it has.

Yet hospitals and emergency departments have been shrinking, while their patient populations have been growing. The Institute of Medicine calculated in 2006 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.

And last month, the American Hospital Association said that bed closures and layoffs were accelerating because of the economic crash. Half of 1,078 hospitals surveyed in March said they were seeing increased numbers of uninsured patients in their ERs, and  approximately 10 hospitals per month were laying off 50 staff or more.

"My hospital has almost no surge capacity; it is running full all the time," Panacek said. "If we had a 10% increase in the need for admissions because of flu, we would have nowhere in the hospital to put those patients. They would back up in the ER, and they would lie on gurneys for days."

Simultaneously, the public health system, which could relieve some pandemic stress by coordinating triage and testing, is experiencing sharp losses of its own. More than 11,000 jobs were eliminated in state and local health departments in 2008 due to budget cuts, according to a letter to Congress written in February by a coalition of public health organizations, and another 10,000 positions are expected to go unfilled this year.

"We still have not built a sustainable system that is not jumping from crisis to crisis," said Dr. Georges Benjamin, executive director of the American Public Health Association. Though alarm over the anthrax attacks and the spread of avian flu triggered several years of robust funding before the current recession, "the process didn't deliver sustained funding that was guaranteed for the long haul," he said.

The result has been thinly populated public health departments and overloaded ERs and clinics all experiencing a foretaste of the overload a virulent pandemic could bring.

At Montefiore Medical Center in the Bronx, which has a high-volume emergency room and 43 affiliated clinics, "we had 3 days of record-setting traffic, 2½ times normal," said Dr. Brian Currie, vice president and medical director for research . The pediatric ER was so overwhelmed that the hospital opened an unused area to create a second waiting room, put up signs explaining the New York City Department of Health guidelines for who should be tested, and sent patient educators into the crowd to talk to parents and urge them to take their children home if they were mildly ill or just concerned, he said.

The patient load at the ER of Goryeb Children's Hospital in Morristown, N.J. has doubled in the past 3 weeks, from 50 children per shift to 100, said Dr. Christopher Amato, an attending physician in pediatric emergency medicine there and at Morristown Memorial Hospital. Some have flu, though it appears on tests to be a late bloom of seasonal flu, he said, and some are part of an outbreak of unidentified gastrointestinal illness that has been flourishing locally since November, but others want checks for minor symptoms.

They include parents whose children have been sent home from school for 7 days under new guidance published earlier this week by the Centers for Disease Control and Prevention (CDC), who are hoping for a doctor's note that will allow the children to return, Amato said.

"I had a child last night who was completely well, afebrile, vital signs stable, exam completely normal, who had been sent home because the school thought he seemed a little hot," he said. "I explained to the parent that they have to go by the CDC guidelines. I can't get between her and the school nurse."

Every hospital reporting an influx of patients with swine flu concerns said that the patients came to the emergency room either because they were sent for a test by school or work, or either did not have a primary care physician or could not get an appointment. Almost none, though, had the severe illnesses that ERs were designed to treat.

By joining the ER queue with mild symptoms, they increased the wait for care for every other patient, including ones with true emergencies, the physicians said. And if they had had a virulent flu, their multi-hour stays could have exposed other patients to the organism, including immunocompromised patients on Medicaid or vulnerable elderly from nursing homes.

If the novel H1N1 flu abates, for the time being at least, the overload of the past weeks could prove a learning experience. "What is good about the current situation is that this allows us to test our preparations, find out where problems exist, and try to mitigate them before the next crisis occurs," Bradin said. "I think we are more prepared than in past, but not to the extent where we need to be."

See also:

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

Institute of Medicine: "Hospital-Based Emergency Care: at the Breaking Point"

American Hospital Association: "The Economic Impact on Hospitals and Their Communities"

Public health coalition letter to Congress, Feb 10, 2009

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