Hospitals prepare for surge in a possible pandemic

Health experts have warned that an influenza pandemic could decrease the workforce by as much as 40 percent, setting off a large influx, or surge, of hospital admissions – one that New Hampshire’s hospitals are preparing themselves for, whether it’s needed or not.

“When you hear about surge capacity, you hear about extra beds, but it’s really so much more than that,” said Deborah Yeager, director of hospital preparedness for the New Hampshire Hospital Association. “Planning for surge capacity is really about maximizing resources — space, beds, equipment and personnel.”

All of New Hampshire’s hospitals, six special care facilities and the NHHA, serving as the main communication liaison among hospitals and state government, have actually been preparing for a flu pandemic for over three years as part of an all-hazards plan, funded in part by the Centers for Disease Control.

That, Yeager said, makes New Hampshire’s hospitals truly ahead of the curve in pandemic preparedness. “We have already addressed questions that others are just beginning to ask. A hospital’s role doesn’t change in the event of a pandemic; it just becomes bigger.”

But planning can be difficult, to say the least, for a disaster that may never become reality.

“Our surge plan is a work in progress,” said Cynthia Gray, chief nursing officer at Derry’s Parkland Hospital, a for-profit entity in the HCA health network that includes Portsmouth Regional Hospital and 190 others across the country. “You’re never quite sure how events will unfold. We’re working in a little bit of the unknown.”

Wes Russell, Parkland’s emergency medical services coordinator, said there’s a distinction to be made in surge capacities, both depending on a number of variables.

“There’s hospital surge capacity, where you’re dealing with issues such as having to care for inpatients in a part of the hospital normally reserved for outpatients. That constitutes an altered standard of care and would need state permission. There’s also community surge and how to manage those that are ill in the community,” he said.

Russell said in a pandemic those who become sick might have to be screened elsewhere outside of the hospital environment “and either admitted, sent home for care there or given prophylactic treatment.”

Yeager also sees home care as the best option for those who are sick, but not critical. Hospitals, she said, “will become big ICUs (intensive care units) for those who are in life-threatening conditions, the sickest of the sick.”

New Hampshire had its first taste in dealing with surge capacity in an avian flu drill that took place last November. Five thousand doses of common seasonal flu vaccines were administered at three sites across the state.

Yeager, who participated in the exercise, pointed out one of the issues that arose from the drill was the need for back-up personnel at command centers.

“Hospitals need to have depth in their organization charts and have more people trained to take on leadership roles,” she said.

Whatever experience New Hampshire’s hospitals may have had with surges of patients, the surge of the ill in a pandemic is far different from a sudden influx of casualties from a major traffic accident, for example.

In a situation like a vehicular pile-up on the freeway or even an airplane crash, the mass of casualties, while sudden and severe, is limited to just one episode. In a pandemic situation, surges occur in wave after wave.

“They tell us it could last for eight weeks,” said Gray.

Other priorities

Surge capacity is not the only issue hospital will have to contend with in the event of a pandemic. Russell and Gray said that New Hampshire’s hospitals also are focusing on infection surveillance. Hospitals would work closely in conjunction with local and state public health officials in identifying new cases and the spread of the disease.

The management of vaccinations and antiviral drugs also is a critical priority for New Hampshire’s hospitals.

“If and when a pandemic viral strain is identified, it will still take six to nine months to develop a vaccine,” said Lynda Caine, director of infection control at Manchester’s Elliot Hospital. “This kind of vaccine is different from the seasonal flu vaccine, which contains several types of weakened or killed viruses. A pandemic vaccine would contain just that one virus. And you would need to be vaccinated with a second booster shot to give immunity.”

Other resources also will have to be procured, ranging from personal protective equipment and ventilators to laboratory testing supplies and beds themselves.

“We’ll need more of everything,” Caine said.

Caine also said hospitals would also have to think more broadly about their services and postpone elective surgeries and community events such as education programs in the event of a pandemic to free up staff for patient care.

Interestingly enough, hospitals are not necessarily considering diverting patients to other hospitals, a situation that most often occurs in emergency rooms or critical care units that are filled to capacity.

“Our philosophy is not to divert in general,” said Caine of the 296-bed Elliot Hospital. “Of course it is possible. It would depend on the situation.”

Learning from Katrina

Even if beds are available at hospitals, will there be enough nurses and other medical staff to care for them?

“It’s capacity versus capability. That’s a tough nut to crack,” said Yeager of the hospital association.

In addition to educating employees about the illness and its prevention in the hopes of reducing a lost workforce, hospitals also are considering deployment of unlicensed volunteers who meet the state’s approval to provide a specified level of care.

Having staff out due to illness or caring for sick family members begs seemingly mundane questions of how to handle situations when employees have used up all their vacation and sick leave.

Gray and Caine both said employees would most likely use their leave banks, and if out longer, start using their short-term disability benefits.

Gray said Parkland is considering day care for employees’ children and frail elderly family members to help ease the staff’s burden of obligations at home.

“Katrina taught us a lot. Employees need to be able to care for their children, and even pets,” she said.

“The important thing to know is that New Hampshire’s hospitals not necessarily just planning for an avian or flu pandemic,” said Parkland’s Russell. “We’re planning for a wide range of emergencies that create surge. We’re not recreating the wheel for every situation. We’re taking an all-hazards approach.”

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