Hospital planning ahead for bird flu pandemic
ED plays critical role in developing response plan
The staff at the University of Utah Hospital, Salt Lake City, is taking a proactive approach to the possibility of an avian flu or other influenza pandemic, and the ED is playing an integral role in the development of the response plan.
"I think the ED is one of most important elements [in creating a plan]," says Colleen Connelly, RN, BSN, emergency preparedness manager. "They have a better understanding of triage, but beyond that, they have a better feel for telling people who need help that they have to wait; that's a skill that no one else in the hospital has clearly defined."
In any emergency response, triage capability is clearly paramount, she says. "It's not like this would occur within 24 hours; it will be a slow buildup," she predicts. "And we will depend on the ED to help us identify those initial patients coming in, making sure we have effective use of personal protective equipment and that we separate the infected patients from the rest of the people in the hospital."
Because of those skills, she says, the ED is intimately involved in the development of triage protocols, which must be specifically crafted for pandemic response. "For example, we will not have enough ventilators, so who gets them?" Connelly says.
Accordingly, she says, Gerald Doyle, MD, an ED physician and assistant professor in the Division of Emergency Medicine at the University of Utah, is part of the emergency preparedness policy group that makes decisions for areas such as triage, ventilator use, and antiviral distribution.
Worst-case scenarios
Doyle's approach is to look at worst-case scenarios such as lack of resources. "There is not one of those problems we can solve ideally, but if we adapt to them and put together a good plan, we can maximize our chances of success," he explains.
So, for example, while the Centers for Disease Control and Prevention (CDC) has statistics available from the 1918 avian flu pandemic, Doyle notes that their value is limited due to changes in medicine and the advent of air travel, which, of course, enables a more rapid spread of the disease. "I don't think we have a handle on what we're dealing with, which makes it harder to plan," he says. "Also, more people are walking around with immunodeficiency and diabetes, making the playing field vastly different."
These changes, in turn, will affect triage protocols. "We expect those individuals to be sicker and more subject to lung disease, for example, so we're looking at incorporating those factors into our triage protocols," Doyle says. For example, he notes, the group is considering the use of community-acquired pneumonia (CAP) scoring systems developed by organizations such as the Centers for Medicare & Medicaid Services.
Many patients on 1 ventilator?
Doyle says he also is looking at new developments in academic medicine that may enable placing several patients on a single ventilator, as outlined in an article just published on-line in Academic Emergency Medicine.1 The reality is that with shrinking bed capacity and fewer ICU beds, we do not expect we will have enough ventilators to go around," he says.
ED staff members are not comfortable with the concept of having several patients attached to a single ventilator, Doyle says. "We've been taught for so long that you have to isolate people to prevent the spread of infections that this is a pretty amazing proposal," he concedes, "But it may be something we need to do."
Others, such as Vortran Technology in Sacramento, CA, are designing simple, relatively inexpensive disaster ventilators. "But this speaks to an overarching concern of mine: What will the standard of care be?" Doyle says.
As much as it bothers him, Doyle says that it may be necessary to accept that lower standard of care when developing a realistic disaster preparedness plan. "To deal with a pandemic outbreak, there very well may have to be a decrement in the level of care people get," he admits.
For example, he points out; the CDC says that anywhere from 10% to 40% of the health care work force will not show up for work during a pandemic. "With a strenuous burden on the nursing staff already due to shortages, people will have to start looking at ways to get around that — and keeping people cared for may need some major adjustments," Doyle suggests.
What might some of those adjustments be? "At some point, we may have to largely focus around just comfort measures," he predicts. "People may not have all their linens changed as frequently, and more self-care may be required in terms of bathing and so forth."
But that's not the worst of the scenarios Doyle envisions. "It may get to the point where we won't get things we rely heavily on that are provided by contractors, such as liquid oxygen," he says. "If their trucks don't arrive, we may have to ration it."
This also could happen with drugs, he says. "If we need Tamiflu and it's just not out there, we may need to ration it or limit the dosages," he says.
Reference
- Neyman G and Babcock Irvine C. A single ventilator for multiple simulated patients to meet disaster surge. Acad Emerg Med published Aug. 2, 2006, as doi:10.1197/j.aem.2006.05.009.
Sources/Resources
For more information on emergency planning for a pandemic flu outbreak, contact:
- Colleen Connelly, RN, BSN, Emergency Preparedness Manager, University of Utah Hospital, Salt Lake City. Phone: (801) 585-3134. E-mail: [email protected].
- Gerald Doyle, MD, Assistant Professor, Division Emergency Medicine, University of Utah, Salt Lake City. Phone: (801) 581-2730. E-mail: [email protected].
For more information about the Centers for Medicare & Medicaid Services (CMS) scoring system for community-acquired pneumonia, go to the CMS web site: www.cms.hhs.gov. In the search box, type "CAP + scoring." Then, click on "HQI Composite Ranking Index Calculation."
For more information on disaster ventilators, contact: Vortran Technology, 3941 J St., No. 354, Sacramento, CA 95819. Phone: (800) 434-4034. Web: www.vortran.com/vortran.html.
The staff at the University of Utah Hospital, Salt Lake City, is taking a proactive approach to the possibility of an avian flu or other influenza pandemic, and the ED is playing an integral role in the development of the response plan.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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