Jul 9, 2008 (CIDRAP News) A study from Indiana reveals a long list of problems hampering county-level planning for pandemic influenza, ranging from misunderstanding of the threat and lack of coordination and resources to rivalry between hospital systems.
Interviews with health officials in 11 Indiana counties showed recent progress in pandemic planning, but also pointed up many difficulties, according to the report in the Journal of Homeland Security and Emergency Management.
Among misunderstandings, some planners thought a pandemic would involve such high rates of illness and death that planning would be useless, and many officials had unrealistic expectations about getting help from outside sources such as the National Guard or the state governor.
In addition, planning and coordination were hindered by blurry agency roles and mismatches between political boundaries and local healthcare market boundaries. The study also showed that most hospitals were hoping to deal with the influx of pandemic flu patients largely by reducing demand for services, mainly through triage systems.
The study was part of an effort by researchers at Purdue University to develop a planning template for ways to provide surge capacity to care for a flood of patients during a pandemic. The researchers interviewed public health, emergency preparedness, and hospital officials in 11 representative Indiana counties between November 2006 and August 2007; questionnaires were tested in two other counties. Interviews were conducted by telephone and on-site.
The researchers, with George H. Avery as first author, found that planners generally had made progress but had a long way to go.
"While planners, for the most part, were committing a significant effort in trying to develop a pandemic influenza plan, and in fact had made large strides over the previous year, the plans developed were still crude and required much more work," the report says.
The scientists grouped their findings into six categories: impact perception, planning and coordination, staffing, logistical and financial barriers, demand management, and dealing with other healthcare needs during a pandemic.
Misperception of the threat
In some counties, officials' view of the likely impact of a pandemic amounted to "a synthesis of misinformation, resulting in a perception of impact which exceeds the worst cases historically observed," the article states.
For example, several counties expected illness attack rates greater than 50% and a case-fatality rate of 50%. The researchers determined that officials derived this view by linking the high case-fatality rate in the (rare) human cases of H5N1 influenza with the high attack rate in the 1918 pandemic.
"This is aggravated by federal communication efforts that confuse the two," the researchers write.
"This confusion resulted in a sense of helplessness among some planning teams, resulting from a belief that any planning would be rendered useless by the magnitude of the problem," the report states. "This indicates a need for more care in risk communication by federal, state, international, and academic public health experts."
In the realm of planning and coordination, one major problem was that political boundaries "bear little resemblance to the geography of local healthcare markets, resulting in a mismatch between the way resources are used and the plans formulated for using them to meet the demands of a pandemic."
"With few exceptions, planners failed to look beyond their borders, whether to identify resources to support their population or to identify additional demand for resources in their jurisdiction," the researchers write. "Because planning responsibilities are defined by local political jurisdictions, most focused only on those jurisdictions, with efforts to initiate intercounty cooperation rarely noted."
The authors suggest that, given the differences between political units and healthcare service areas, planning for providing surge capacity would be better done at the regional level than the local level.
The researchers also found various other problems in planning and coordination, including:
- Vagueness regarding the roles and responsibilities of local public health, emergency management, and healthcare officials
- Rivalry between hospital systems that impaired coordination (though it was found that a mediator could reduce this problem)
- Unrealistic expectations for outside help, such as material support from the National Guard or the governor's officea misperception grounded in experience with localized disasters such as floods
Using retired physicians, student nurses
Concerning staffing, the counties generally had tried to follow guidance in the federal pandemic flu plan, but they ran into some problems with it. For example, most counties had begun to develop a reserve list of retired or inactive physicians and nurses who could help in a pandemic. But local officials complained of a lack of state guidance on licensing and credentials, and few had addressed the problem of malpractice insurance for those workers.
In addition, "Several counties with nursing schools operating within their borders have explored the idea of utilizing nursing students as care extenders, but the efficacy of this will depend in part on school decisions on how to respond to a pandemic event and whether to continue operations," the report says. Also, it was not known whether any of the counties had checked whether students were willing to serve.
On the logistical and financial front, the leading concern was possible shortages of medical supplies, especially drugs and personal protective equipment, the researchers found. The economic pressure to run lean operations was cited as an obstacle to the stockpiling of supplies for emergency use.
Hospital officials expressed concern about making ends meet during the pressures of a pandemic, the study says. One hospital thought it would have to shut down, while others suggested they would have to rely on federal and state disaster assistance funds to get by. "Few considered the fact that most patients would be insured and that they could use usual mechanism to seek reimbursement for care which might provide a revenue stream," the authors write.
One county hospital that looked into insurance reimbursement during a pandemic learned that care would be covered only if it was provided in the hospital's own facility, a restriction that would limit options for expanding capacity, the report notes. Other hospital officials assumed that the pressures of a pandemic would drive insurers into bankruptcy.
Managing demand
Most of the counties chose to deal with hospital capacity problems during a pandemic at least partly by reducing the demand for hospital services, usually by means of a triage system to save hospital beds for those in greatest medical need, the researchers found. Because of concern about spreading flu, officials were discussing plans to separate flu patients from other patients or to locate triage functions outside the hospital, such as in tent clinics or school gyms.
Local officials were also looking at other tools to limit demand for hospital services, including "public information efforts to convince those with the disease to utilize self-care when possible, creation of dedicated outpatient flu and fever clinics, and public education programs to prevent exposure by encouraging social distancing," the report states.
In line with these plans, nearly all counties had a basic communication plan to inform the public about the disease and the local response and to direct patients to the most appropriate source of care. However, many county planners focused only on media services located within the county, rather than the sources most used by the local citizenry. For example, one surburban county planned to use the only radio station based in the county, a college station with a weak signal, instead of higher-rated TV and radio stations in the next county.
A message the researchers heard from all the counties was that flu patients would not be the only demand on healthcare organizations during a pandemic. Officials said other healthcare needs would continue, such as trauma, childbirth, and medical emergencies. Consequently, not all beds could be allocated to flu patients, and hospitals will need to take steps to prevent flu from spreading to other patients.
In the face of this reality, "Almost all counties were giving consideration to altered standards of care to stretch resources, but were wary of this option due to liability concerns and lack of statutory protection from malpractice claims, a concern heightened by lack of guidance from state and federal governments," the report states.
Among lessons drawn from their findings, the authors say that legal and institutional barriers may limit planning in ways that are not obvious and that planners may not have the authority to address such problems. "Issues such as insurance reimbursement, malpractice and liability insurance, and scope of practice rules constrain the solution set for local planners, and require policy action at a state or federal level to solve," they state.
They also note other researchers' observation that the idea of using alternative sites to provide surge capacity in a pandemic is widespread, but it is not clear just how these sites would work or even if they would be feasible. They write, "Significant barriers exist to the use of alternative care sites for building hospital surge capacity, and any attempt to develop such capacity should focus on how alternative care arrangements fit into the overall local emergency management and healthcare systems. More important than the alternative care site is the strategy for an alternative care system."
Avery GH, Lawley M, Garret S, et al. Planning for pandemic influenza: lessons from the experiences of thirteen Indiana counties. J Homeland Secur Emerg Manage 2008;5(1):29 [Abstract]
