On the frontlines of emerging pandemic
Hospital limits entry, creates H1N1 clinic
The rural Iowa community of Marshalltown may seem an unlikely place to be an epicenter of a new pandemic. But this spring, the town of about 26,000 coped with a sudden outbreak of novel H1N1, demonstrating why pandemic preparedness is so important for every hospital.
As soon as the first case was identified as a possible or probable case in late April - a young Marshalltown man in his 20s who had traveled to a part of the United States with confirmed cases of novel H1N1 - Marshalltown Medical & Surgical Center assembled its Flu Task Force Committee. The task force brought together key players in administration, infection control, public health and employee health, as well as other nursing directors and ancillary department directors.
On Friday, May 1, the task force brought together additional representatives from the Marshall County Pandemic Flu Committee, community physician offices, schools, county and city government, nursing homes, and others. An average of 60 to 80 members met every day at 7:30 a.m. until the outbreak subsided, and the hospital staff held daily conference calls with the Iowa Department of Public Health.
By Saturday afternoon, anticipating an influx of suspected H1N1 patients, the hospital opened a new on-site clinic and established a 24/7 call line to provide advice to anyone in the community who had symptoms. Throughout the outbreak, the call line received nearly 600 calls.
"We have a very diverse population here in Marshalltown. With the recent spring break for students and the upcoming Cinco de Mayo celebrations we knew there were many families who had traveled back and forth to Mexico [where the novel virus emerged and a significant outbreak was ongoing]," says employee health coordinator Debra McAteer, RN.
Over the next several weeks, that clinic cared for nearly 400 patients, with an average patient age of 15. The hospital ultimately saw more than 60 confirmed cases, with many more than that likely to have the virus in the community. By the second week of the outbreak, the state department of health asked the hospital to send samples for further testing only for potentially exposed health care workers and patients who were at high risk for complications, such as pregnant women, hospitalized patients, children younger than 5 years old, or individuals with other significant health conditions.
In fact, throughout the outbreak, testing was a huge challenge. "All specimens would come in to the MMSC lab and then be packaged and sent to the state lab. The state lab would run the initial test and if it came back as a probable case they had to send it to the CDC," recalls McAteer. "CDC was so backlogged that a test that would normally take 24 to 48 hours was taking seven to 10 days, which is a huge delay in time when you're trying to figure out what's going on in your community."
To prevent transmission of the novel virus in the hospital and to protect employees from exposure, Marshalltown Medical & Surgical Center relied on symptom screening of patients, family members, visitors, employees, and volunteers. (See sample screening tool.)
"We had very few [occupational] exposures. The first couple of patients were our main unprotected exposures because we didn't know we had it in our community yet," says McAteer. Those employees with a significant exposure to the virus were offered antiviral prophylaxis and were told to watch for symptoms, she says.
The special H1N1 outpatient clinic (an extension of the ED) was close to an exterior door and could be closed off from other parts of the hospital. Meanwhile, the hospital closed all doors except the front entrance and the ED entrance. Every person entering the hospital was screened using a screening form that was available in English and Spanish.
Employees, visitors, and contractors who came in and out of the building regularly received a small card indicating they had been screened. Then they would simply answer a brief symptom check to receive access every time they came into the hospital. This card was good for a seven-day period. The hospital staff positioned at the entrances screened more than 3,000 individuals before the protective access was canceled.
To alert the public to the new restrictions, the hospital placed a full-page ad in the local newspaper and provided updates through biweekly press conferences. "People in our community were very understanding of why we were restricting access," says McAteer. "Our public relations department did a fabulous job of getting the information out in the community and to the people who needed it most."
Round the clock fit-testing
Protecting employees also was clearly a priority. The hospital had previously purchased powered air-purifying respirators (PAPRs) and had hoods available to employees who were likely to have exposure to patients with tuberculosis or other highly infectious airborne diseases.
But with H1N1, employees in many other areas of the hospital, such as the business office and Health Information Management offered to volunteer to help as screeners. "They were not in the current plan as being trained for a respirator because they were not direct care providers," says McAteer. "They also wouldn't need their own PAPR hoods after the outbreak subsided, so fit-testing them for an N-95 respirator made more sense at the time of the outbreak."
The hospital began a week of around-the-clock fit-testing of an additional 550 employees, volunteers, school nurses in area schools, and others who would use N95 respirators as needed. If they failed the fit-testing, they were trained to use the PAPR. The state released some personal protective equipment from the national stockpile for the hospital to use as needed.
"We had previously decided to use our PAPRs at all times instead of having to fit-test all of our employees to the N-95 every year. We just do not have the time, personnel or the monetary resources to fit-test yearly," says McAteer. "In the future, I think there will be a handful of people we will continue to fit-test on a yearly basis so on a moment's notice they'll be ready to use either the N-95 or the PAPR."
At the height of the outbreak, Marshalltown schools were closed for three days. But while some have wondered whether absenteeism of health care workers would rise during an outbreak - especially with school closings - employees actually offered to work overtime or extra shifts to help out.
State breaks with CDC
As the outbreak subsided, and the public health community saw that the novel H1N1 was not causing severe disease in the United States, the Iowa health department changed the recommendations for PPE to surgical/isolation masks rather than respirators (droplet precautions), except for aerosol-generating procedures such as nebulizer treatments or intubation. Employees working in the H1N1 clinic continued to use PAPRs until it was closed, as it was a small space without negative pressure rooms, says McAteer.
But McAteer cautions that the definitions that CDC and public health used when determining severity of the virus were somewhat misleading to the community. CDC characterized the novel flu as mild. Although there were few hospitalizations, the disease did cause significant disruption, discomfort, and absenteeism from school and work.
"People were truly very, very ill with this virus. We were very lucky that none of our clinic patients needed to be admitted to the hospital," she says.
"People had fevers of 103°, 104°, or 105° for a few days. They were still coughing for seven to 10 days or more," McAteer adds. "There were other symptoms, like coughing, sore throat, some nausea, vomiting, and diarrhea, which aren't typical with respiratory flu."
After the outbreak subsided, Marshalltown reviewed its response and conducted a comprehensive debriefing with the Iowa Department of Public Health. Among the lessons learned: "Remember to be flexible (thinking outside the box is a good thing) and to communicate, communicate, communicate," says McAteer.
The rural Iowa community of Marshalltown may seem an unlikely place to be an epicenter of a new pandemic. But this spring, the town of about 26,000 coped with a sudden outbreak of novel H1N1, demonstrating why pandemic preparedness is so important for every hospital.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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