Published in the September 2009 issue of Today’s Hospitalist
One of the first signs that H1N1 influenza had hit Bel Air, Md., was the number of flu tests being sent to the lab at Upper Chesapeake Medical Center. Doctors typically order only 10 flu tests there during the month of June. But that month, that testing burden increased many-fold.
“We were doing over 100 tests,” says Faheem Younus, MD, one of the hospital’s infectious disease specialists. “Out of that testing, we noted 30 patients who came back positive for influenza A during the month, including some swine flu. That was the first thing that changed.”
This summer, while the World Health Organization declared that international swine flu levels had reached pandemic proportions, the CDC estimated that 1 million Americans had contracted the novel strain. Regional infections occurred throughout the Northeast and South, while California, New Jersey, Maine, Georgia and Maryland reported widespread infection.
At press time, more than 430 Americans have died from swine flu “a fraction of the number who succumb to seasonal influenza. The vast majority of swine flu cases seen in emergency departments this summer were mild, with most patients being discharged home.
Still, physicians confirm the strain’s unusual presentation. Hospitalists report seeing more vomiting and diarrhea in hospitalized H1N1 cases than in patients with seasonal flu. And instead of striking the very young and the very old, the virus affects more children and middle-aged patients. (See “Swine flu facts”.) While very few of the H1N1 cases diagnosed at Upper Chesapeake were admitted, Dr. Younus says that the severity of disease in one otherwise healthy 50 year-old who had to be intubated was “pretty shocking.”
As the H1N1 virus continues to spread, facilities that grappled with it over the spring and summer are busy reviewing the lessons learned from that first wave. They are also keeping a watchful eye on what health organizations say may be an explosive resurgence of swine flu this fall.
An influx of “worried well”
While many facilities affected by swine flu saw unusually crowded emergency departments this summer, few hospitals were reporting strained capacity. Hospitalists working seven-on/seven-off shifts, for instance, were not being pulled back into the hospital on their weeks off, nor were hospitals running short of masks or supplies of oseltamivir (Tamiflu).
But that doesn’t mean that the presence of H1N1 was easy to ignore. Widespread media coverage successfully relayed information about flu symptoms to the public, but also brought out “the worried well.” The solution at Virtua Memorial Hospital in Mt. Holly, N.J., was to set up a process in the ED for patients with flu-like symptoms to be examined, treated if needed and released.
“A lot of those people just really needed to be reassured,” says Alka Kohli, MD, the hospital’s medical director of operations, “so they could go home.”
At Upper Chesapeake Medical Center, Dr. Younus says the severity of illness in some hospitalized patients led the medical center to change its isolation protocol. While patients with seasonal flu are typically isolated for seven days from the onset of symptoms, physicians this summer decided to extend that period of isolation for very sick swine-flu patients to 10 or 14 days.
And in Northern California’s Sacramento County, which had 200 diagnosed cases county-wide as well as two deaths, the prevalence of swine flu now complicates all inpatient care, according to hospitalist Cecilia Hernandez, MD, director of medical affairs for Sutter Medical Center, Sacramento. That’s because hospitalists have to consider swine flu as part of a differential diagnosis.
Instead of relying on well-established protocols for assessing and treating patients hospitalized with other conditions who develop a fever, Dr. Hernandez says “We currently consider testing specifically for H1N1 and begin treatment with Tamiflu if a patient develops fever, pharyngitis and a cough.”
Sutter Medical Center is also considering changing its protocol for managing obstetric patients who may have the virus. “Our understanding of CDC and state recommendations is to consider separating newborns from mothers with suspected or confirmed H1N1,” Dr. Hernandez says, adding that such a move could hurt maternal-newborn bonding and the successful initiation of breastfeeding. “Swine flu brings a level of complexity that was not there before.”
A broad communications role
Inpatient physicians also found themselves having to communicate key information to many different constituents. Dr. Younus’ infectious disease group, for instance, helped author a letter to community physicians, updating them on swine flu and letting them know that state labs would not be able to process tests for patients who were not hospitalized.
“We told primary care physicians that for flu-like illness in the community, just do regular flu testing,” Dr. Younus says. “If the test is positive for flu A, assume it’s swine flu and treat it as such, but don’t send that specimen to the state.”
In the hospital, however, “the exact opposite scenario was in place,” he adds, which needed to be communicated to ED personnel. “For patients who look very sick and have a negative regular flu test, that doesn’t rule out swine flu,” he says. “The ED needs to send those tests out to state labs.”
At Virtua Memorial, the hospital needed to communicate with outpatient physicians to spell out which patients should be sent to the ED.
“We told primary care physicians to try to triage by telephone and, if patients with flu-like symptoms were coming to the office, to have a separate waiting area for them,” Dr. Kohli explains. “We also told them to treat patients with Tamiflu and to send only those patients to the ED with additional problems beyond typical flu symptoms, such as shortness of breath.”
TeamHealth, a national management company based in Knoxville, Tenn., that staffs both ED and hospitalist programs, has provided materials to its physicians and client hospitals to distribute. The goal is to get those materials to high-risk patients, such as those with asthma.
“We suggest sharing this information with pulmonary clinics, cardiologists, primary care physicians who are the ones caring for diabetic patients, and obstetricians,” says Christopher Frost, MD, TeamHealth’s vice president of hospital medicine and clinical excellence. “You need to target education to high-risk populations.”
A rush for prophylaxis
Hospitals have also had to decide how frequently they should update information going to community physicians and medical staff. At Upper Chesapeake, Dr. Younus says, the hospital opted for one succinct missive to outpatient physicians and ED personnel, with the infectious disease physicians relying on personal communications with those doctors thereafter.
“You need to keep it concise and just hit a few major points because once you go beyond a paragraph, people don’t read it,” says Dr. Younus. “If you send out alerts daily or too frequently, that can desensitize people.”
In Sacramento, however, Dr. Hernandez says that the hospital convened a task force that meets weekly to review recommendations from the CDC and the state public health department. That review becomes the basis for e-mails and mass faxes to outpatient providers and hospital staff.
“Our strategy has been to communicate often and as widely as possible, right from the beginning,” Dr. Hernandez points out. “I think that actually has led to less panic because people know we have a plan in place to keep them informed.”
At Santa Rosa Memorial Hospital in Santa Rosa, Calif., Aynna Yee, MD, who directs the hospitalist program, says that hospitalists over the spring and summer treated seven confirmed H1N1 inpatients. She notes that hospitalists needed to communicate with nursing staff, many of whom approached the physicians for prescriptions for prophylaxis for themselves or family members.
As a result, the hospital distributed a flyer to nursing staff that outlined the personal protective equipment needed. “All patients with H1N1 wear standard surgical masks,” Dr. Yee says. “Physicians and nurses use N-95 masks and add goggles and gowns when obtaining a swab or providing respiratory therapy.”
The flyer also spelled out who would meet prophylactic criteria. Those include health care workers exposed without adequate droplet protection to swine flu patients, up to seven days after exposure. As for patients’ families, the flyer made clear that only high-risk family members of H1N1 patients “those who are immunocompromised, or age 65 and older with comorbidities ” would qualify for prophylaxis.
The impact of younger patients
Hospitalists were also the point people for communicating with H1N1 patients and their families. The fact that the H1N1 patients at Santa Rosa Memorial who were hospitalized were middle-aged, ranging in age from 20 to 50, was, Dr. Yee says, “why most people are shocked or scared of this.”
“They feel that if their family member who’s fairly young is getting this, then they’re susceptible too,” she says. “It just hit home.” According to Dr. Yee, hospitalists continue to stress to patients and families that “the relative danger of this current H1N1 is much less than that of seasonal flu.”
The bad news, Dr. Yee says, is that unlike this summer’s wave of virus, swine flu’s expected resurgence “will be at the same time as seasonal flu. Patients will have to be educated to get both the H1N1 vaccine, when it’s available, and seasonal flu vaccine.”
The good news, she points out, is that “there’s no indication at the moment that the virus has mutated” to become more lethal. However, Dr. Younus notes that Tamiflu-resistant swine flu strains have been detected in other countries.
“This virus has already crossed four different genes, two from swine and one each from birds and people,” he says. “This virus can mutate, and it could be a very different virus that we have to deal with in six months.”
That makes it a challenge, Dr. Younus points out, to develop an effective vaccine. “I think we should be very prepared,” he adds.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Hospital preparedness drills begin to pay off
EARLY LAST MONTH, Alka Kohli, MD, medical director of operations at Virtua Memorial Hospital in Mt. Holly, N.J., was taking part in a week-long, state-run exercise for hospitals in dealing with pandemic flu. Every morning that week, she and senior staff took part in a two-hour conference call to discuss how the hospital would respond to escalating scenarios.
Here was the one presented on day three: At the end of September, there are 50 million confirmed H1N1 cases in the U.S. and 3 million deaths, a 6% mortality rate. There are worldwide shortages of antivirals, food and critical supplies, and 50% of the hospital staff aren’t reporting to work, either because they are sick or they’re caring for family members. Ten staff members have died of H1N1, and all hospital surge areas are at full capacity.
“It’s a very valuable exercise,” Dr. Kohli says. “It helps us think through such a scenario step-by-step in a simulated exercise.”
As hospitals around the country deal with the first H1N1 wave, hospitalists and infectious disease specialists say that the stepped-up attention paid to hospital disaster preparedness “particularly in the wake of Sept. 11 “has paid off well this summer. Many hospitals have had disaster preparedness teams in place for several years and have participated in several disaster drills. Dr. Kohli, for instance, says her hospital took part in a similar exercise two years ago that looked at how well the health system would potentially respond to severe weather hitting the Jersey shore.
Hospitals are also reviewing options for “what ifs” in the event of more serious H1N1 resurgence. Christopher Frost, MD, vice president of hospital medicine and clinical excellence for TeamHealth Hospital Medicine, a Knoxville, Tenn.-based national hospitalist management company, says his company has prepared materials for client hospitals that discuss cohorting patients in a pandemic crisis.
“To mitigate the risk of spreading illness, we would likely need to have floors in our hospitals dedicated to these patients, and have dedicated hospitalists as well as nursing staff,” says Dr. Frost. “You’d have to make sure that, if there is any vaccine rationing, there are plans to give these providers prophylactic therapy.”
During last month’s exercise, Dr. Kohli and senior staff discussed using dedicated hospitalists in the hospital’s conference centers, which would be one of the surge capacity areas. They also looked at what auxiliary distribution chains might be available.
They discussed how the hospitalists, who are now on a seven-on/ seven-off schedule, would be pulled into the hospital during their weeks off, and when elective surgeries would be cancelled.
They also talked about credentialing community physicians who likewise may need to be pulled into the hospital and at what point specialists, who now have hospitalists admit their patients, would need to revert to their own admissions. And they discussed the more active clinical role that nurse practitioners and nurse educators would play in a pandemic emergency.
At Sutter Medical Center, Sacramento, hospitalist Cecilia Hernandez, MD, says that staff members are developing contingency plans to deal with N-95 mask shortages, including tapping the county’s mask cache for individual hospitals.
The hospital is also assessing its Tamiflu supply on a weekly basis. Says Dr. Hernandez: “That’s all being looked at.”