ACEP releases H1N1 strategic plan
'No area of the United States would be spared'
Two out of the three pandemics in the 20th century made a first pass and then returned in a more virulent "second wave." Give that historical precedent, EDs departments should prepare for a surge of patients with respiratory symptoms this fall as H1N1 novel influenza A takes a shot at North America during a traditional flu season.
"No area of the United States would be spared from the spread of novel H1N1," the American College of Emergency Physicians (ACEP) warns in a new report. "Although the weather may affect transmission rates, no emergency department is exempt from the risks of an outbreak. If the transmission rates double from the spring 2009, more than 30,000 cases can be expected over the fall and early winter. Emergency departments could see 150% of normal volume of respiratory complaints. This may even be true in communities where the novel H1N1 virus is not yet widely present due to increased levels of concern by the public regarding any respiratory related illness."
The American College of Emergency Physicians (ACEP) is making public a "National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza" to help the nation's EDs and first responders plan for and manage the surge in H1N1 flu cases that might arrive as early as September (Editor's note: A copy of the plan is available at tinyurl.com/klb2ss.) The plan, which was produced under the Office of the Assistant Secretary for Preparedness and Response (ASPR) and the Emergency Care Coordination Center (ECCC), includes the following key components:
- threat awareness;
- protection and prevention;
- surveillance and detection;
- response and recovery.
Second, more virulent waves occurred in the fall in the pandemics of 1918 and 1957, ACEP points out. "Should a second wave occur in the early fall, a vaccine is unlikely to be available," the report states. "Without vaccine, the best defense the nation will have in reducing transmission would be community mitigation strategies. Since case rates are highest in school-aged children, school closures would likely be one of the first strategies employed. This would result in parents needing to remain home with their children and the consequent loss of workplace productivity. This would include health care workers, reducing the ability of emergency departments and hospitals to function at peak efficiency."
ACEP recommends that emergency departments make the following planning assumptions:
- The behavior of the virus is not predictable but is likely to return in the fall of 2009 and persist into 2010, complicating usual seasonal flu management.
- The fall 2009 wave will follow the pattern of pandemics of the 20th century by having greater virulence than the initial wave.
- Children and young adults will experience the highest attack rates.
- Adults older than 65 will have lower attack rates due to previous influenza exposures.
- The onset of the fall wave will not be detected until after it has begun.
- A well-matched vaccine will not be available until mid-October 2009 at the earliest and will not be effective until weeks after the final doses.
- Community mitigation measures can be effective to slow disease transmission and will be the only tool available for prevention.
- Mass antiviral chemoprophylaxis will not be recommended.
- Continuing sensitivity of H1N1 to antiviral medications is unknown.
- Emergency medical and hospital planning for an H1N1 pandemic will be successful only if it is interoperable with emergency management and public health.
The release of the plan "[s]hould encourage people — if they haven't already — to start their planning process and identify other groups they have to work with," says Stephen V. Cantrill, MD, FACEP, an emergency physician at Denver Health Medical Center and a member of the task force that developed the plan. "As you know, we tend to think of ourselves as 'stand-alones,' but the ED needs to work with hospitals, state and local health departments, local, state, and federal government, and emergency medicine partners throughout the country," Cantrill says.
Among the goals of the plan was the development of a capabilities list — a "starting place" for ED managers and others for determining the capabilities they would have to have to deal effectively with a potential pandemic outbreak, he says. Those capabilities will vary from hospital to hospital and town to town, Cantrill says. For that reason, the plan is designed as a foundation upon which emergency planners will build their own customized plan.
"Our goal is always to provide good patient care, and this will optimize those opportunities," Cantrill says.
Once the emergency response planners have taken the ACEP plan and molded it into their own institutional plan, it must be shared with staff, he says. "They need to know what is expected of them in terms of things like personal protective equipment and absenteeism policies," Cantrill notes. "For example, while you may want to come in to work, we do not want you to work when you are sick."
As in any pandemic, staffing would be one of the biggest challenges, says Cantrill, citing the importance of ED managers being aware of many possible sources of staffing help. "For example," he poses, "do you have a list of volunteer retired caregivers? It's not something you want to spool up when the need arises, but rather give thought to it ahead of time."
WHO issues H1N1 patient care checklist The World Health Organization (WHO) has developed a new free Patient Care Checklist for Influenza A (H1N1) for use by hospitals worldwide for the treatment of suspected or confirmed cases of the virus. "All hospitals are being encouraged to use the checklist and, where appropriate, to modify it to suit their local practice," says a statement from WHO. WHO recommends disseminating the checklist "as soon as possible," since "[t]his is critical for health management, as well as clinical practice, to ensure the fullest possible uptake." WHO adds that the checklist is currently being evaluated "to improve usability" and an updated version will be posted on the web site when completed. The checklist can be downloaded at: www.who.int/patientsafety. The web page also includes a brief summary of the checklist and how WHO suggests it be used. |
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