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As newspaper headlines track the avian flu's path around the globe, U.S. health officials are playing catch-up in their efforts to prepare for worst-case scenarios. Experts project that more than half a million Americans could die, and more than 2 million could be hospitalized in the event of a U.S. pandemic flu outbreak.
With the federal government outlining an ambitious $7 billion pandemic flu initiative, it's up to state and local governments and hospitals to prepare employees and upgrade facilities.
Many hospitals and health systems are developing incident command systems and running readiness exercises. Yet as the Yale New Haven Health System in Connecticut begins marking items off an avian flu preparedness checklist, Christopher Cannon, system director for the Health System's Office of Emergency Preparedness, warned that hospitals still have a long way to go. "I doubt there is a hospital in the country that is in a comfortable place on influenza pandemic planning," he said.
Besides heading up Yale New Haven's efforts, Cannon is director of an organization dedicated to helping other health-care organizations with emergency readiness. The Yale New Haven Center for Emergency Preparedness and Disaster Response offers training and coordination services to hospitals, skilled nursing facilities, community health centers and emergency medical services. Cannon said hospitals in Connecticut are just starting to work through pandemic issues. For instance, Danbury Hospital in Danbury, Conn., is studying the human resources aspect. "Normally you reward people who aren't absent, but in a pandemic, you may not want to encourage attendance," Cannon said. "So they are having discussions about how this affects HR policies. We are asking them to share their results of that process with other hospitals."
Cannon also believes the ethical issues surrounding pandemic flu haven't yet been dealt with adequately. Most scenarios predict that 35 percent to 40 percent of health-care providers will not show up, some because they are taking care of sick family members. "Then you'll see this surge of very sick people when you have a diminished capacity to take care of them," he said. "How are we going to deal with that?"
Because it's a respiratory illness, providers will have to cope with shortages of ventilators and antiviral drugs, and will be forced to make tough decisions about who gets treated first. "These are very large ethical issues," Cannon said. "Hospital ethics committees really need to get engaged in the discussion now."
Yale New Haven Health System, which has five hospitals, began the process in fall 2005 by adopting a checklist created by the federal Centers for Disease Control and Prevention (CDC). "We are holding meetings with our medical team [and] trying to move the items on our checklist forward at each of our hospitals, but we have a very long way to go."
The framework state public-health and hospital officials are using to develop their plans is a 396-page document published online in November 2005 by the U.S. Department of Health and Human Services (HHS)
Deborah Levy, an epidemiologist for the CDC in Atlanta, said the CDC contributed several chapters to the HHS planning document, including hospital preparedness checklists. The CDC is working with the HHS on further recommendations of action items to be published in 2006. The CDC, Levy said, has led tabletop exercises at eight locations around the country involving a scenario of the avian flu identified on an incoming flight. "How the health-care community responds is one component," she said, "and we looked at how hospitals deal with surge capacity issues." The pandemicflu.gov Web site has templates states and health systems can use to conduct their own exercises, she added.
The HHS document also contains some guidelines public health departments should use in working with hospitals to develop state-based plans for antiviral stockpiling and distribution. The Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America issued a joint statement in October 2005 suggesting that one approach would consist of a rotating stockpile that contains approximately five times as much drug as used in an average influenza season. They also recommend expanding the national stockpile to include sufficient antivirals to treat at least 25 percent, and ideally 40 percent, of the population. Currently the federal government has only enough antiviral treatment courses for approximately 1 percent to 2 percent of the population.
One hospital executive found that running an avian flu drill alerted hospital officials to the amount of work that still needs to be done. Meg Femino, disaster preparedness coordinator for Tufts-New England Medical Center in Boston, said the hospital already participated in two regional tabletop exercises. "But I thought it was important for the whole hospital to realize the impact a global pandemic would have on us."
So in November 2005, Tufts ran a three-hour drill to simulate an avian flu outbreak. "The results were overwhelming on many fronts," Femino said. The drill pointed out surge capacity issues in acute care and the shortage of antivirals and ventilators. It also forced administrators to cope with the estimated 40 percent decrease in staffing expected during an outbreak.
If the drill exposed areas of weakness, it also highlighted progress the hospital has made. In 2004, Tufts implemented a Hospital Emergency Incident Command System (HEICS). The HEICS framework, initially developed by the Orange County, Calif., Emergency Medical Services Authority, is used by many hospitals nationwide as an emergency command organizational structure.
By standardizing job titles, HEICS eases communications between hospitals, Femino explained. As Tufts' liaison officer, she can call Massachusetts General Hospital and ask for its liaison officer, who is responsible for coordinating actions between hospital staff and outside organizations. "I don't have to know that person or even their name, but I know their job tasks in an emergency, so it breaks through trying to figure out who to call," she added. The HEICS also sets up an entire hospital command infrastructure in disaster response. There are specific titles responsible for communications, feeding, facilities, staffing, inpatient/outpatient services, social work and respiratory labs.
HEICS is being revised and renamed the Hospital Incident Command System to gain compliance with the Department of Homeland Security's National Incident Management System (NIMS), the first nationwide standardized approach to incident management and response. All emergency service organizations that receive federal funding are required to be NIMS-compliant by Sept. 30, 2006.
During the drill, pharmacy staff learned the hard way that they must go through proper channels with drug queries. "There are certain protocols that have to be followed if you're going to get to the strategic national stockpile," Femino said. "You have to go through the liaison officer."
She said the drill raised ethical issues about who would get treatment first. "Some states such as Minnesota have come up with plans for cascading of degradation of care, but we have no guidance from the state of Massachusetts on that yet," Femino said. "We should have one policy that's communitywide. We don't want patients thinking some hospitals are treating patients differently."
The exercise helped spawn the creation of a 10-member avian flu- working group on the Tufts hospital campus. Issues to be studied will include staffing redeployment, resource allocation, surge capacity and social distancing -- whether to shut down lectures, change visitor policies or close schools.
"We have to look at these issues now," Femino stressed. "It's too difficult to make resource allocation decisions about ventilators or antivirals in the heat of the moment. You need to establish a clear pathway."
The Show-Me State
The level of effort put into pandemic preparedness to date varies from region to region and hospital to hospital, according to Cannon. One state with a high-profile effort under way is Missouri, where the state hospital association took a leading role in coordinating hospital efforts. "When you're trying to estimate how many patients would need treatment, the numbers are daunting," said Leslie Porth, vice president of health planning for the Missouri Hospital Association (MHA). "The Department of Health and Human Services has estimated that if a pandemic comes, 25 percent of the population would be affected."
Working with the state Department of Health, which gets grant funding from the federal Health Resources and Services Administration, the MHA built a repository of information for hospitals in the state. The organization's Web site
is loaded with disaster preparedness information, including directions on setting up hospital incident command systems that create a consistent framework of clearly defined roles, responsibilities and reporting structures during an emergency. The site also provides hospitals with information on how to acquire additional antivirals from the federal strategic national stockpile. Using scenarios created by the CDC, the MHA is organizing pandemic flu training exercises for local hospitals.
Porth said Missouri's pandemic planning is part of a larger all-hazard planning process. Missouri, like other states, is preparing for any event that would create a surge in the number of patients, and that would require alternate ways to provide care and alternate locations. "A distinction and additional challenge with a pandemic is that there would likely not be resources coming from other locales," she said, "because people in other states would all be in the same position."
The MHA is encouraging hospitals to have repetitive and redundant communications systems such as satellite phones and ham radios. Another facet of communication planning the MHA helped develop is the EMSystem, a statewide, Internet-based communications system linking hospitals, emergency services providers, public health agencies, and the Missouri Department of Health and Senior Services. The system was designed to help hospitals communicate how many beds are available in each unit and share information on public health alerts.
HHS officials are in the midst of a 50-state road show to talk up the importance of pandemic preparedness. At a February summit meeting on pandemic flu preparedness, Missouri Gov. Matt Blunt and HHS Deputy Secretary Alex Azar signed a resolution, committing the state and federal government to planning efforts.
As part of the resolution, the HHS committed to give the state an initial amount of $1.9 million for planning, and will offer technical assistance in reviewing the state's plans for use, storage and distribution of antivirals. The HHS also will notify the state of its portion of the federal stockpile of pandemic influenza antiviral drugs.
For its part, the state plans to establish a Pandemic Preparedness Coordinating Committee. Missouri also committed to notifying the HHS of the amount of additional antiviral drugs it plans to purchase, and will work to complete its preparedness plan within six months.
Porth said 9/11 and Hurricane Katrina have been "a real wake-up call" for hospitals to re-evaluate their preparedness plans. "Each year we are better prepared than 12 months earlier, but I don't think you ever get to the point where you say, 'OK, we're ready,' and just sit back and wait."