# Presentation: 236088

## Healthcare Preparedness and Response Issues

- Patricia M. Simone, M.D.
- Division of Healthcare Quality Promotion
- Centers for Disease Control and Prevention

## Outline

- Healthcare impact
- Role of healthcare system
- Readiness
- Plans and recommendations
- Division of Healthcare Quality Promotion, CDC
- Key healthcare issues
- Role of NVAC Pandemic Influenza Working Group

## Estimated Burden in the United States

- Based on past pandemics, 15-35%  of U.S. population may become clinically ill with influenza virus
- 18 to 42 million outpatient visits
- 314,000 to 733,000 hospitalizations
- 89,000 to 207,000 deaths
- Meltzer et al.  EID 1999;5:659-71.

## Healthcare Impact

- High demand for services
- Estimated >25% increase in demand for inpatient beds, ICU beds, and ventilators for a mild pandemic
- Staff absenteeism
- 1957/58 (UK) 20% absenteeism rate; 1/3 of staff in one hospital was ill during peak
- Limited availability of critical resources

## FluSurge

- Tool to estimate impact of pandemic on community
- Census data
- Hospital data
- Staffed beds, staffed ICU beds, ventilators
- Estimates
- Numbers of hospitalizations and deaths
- Number of beds (ICU and non-ICU) and ventilator capacity needed
- Based on
- Duration of pandemic (weeks)
- Gross clinical attack rate (15, 25, or 35%)

- www.cdc.gov/flu/flusurge.htm

## Estimates Using FluSurge Software

- Example – impact of an 8-week influenza pandemic with 25% gross clinical attack rate
- Demand of hospital resources peaked in week 5
- 27% of all hospital beds
- 54% of total ICU capacity
- 29% of all ventilators
- Total burden
- 9,707 hospital admission (ranging from 3,310 to 12,924)
- 1,741 deaths (ranging from 782 to 3,120)

## Pandemic Response Components

**Vaccination**

**Antiviral treatment **
**& prophylaxis**

**Maintain essential services/ response activities**

**Infection control in healthcare settings**

**Provide quality medical care**

**Interventions to prevent disease  transmission**

**Pandemic influenza disease**

**Time**

**Impact**

## Role of Healthcare System in Pandemic Response

- Provide quality care
- Adequate staffing
- Adequate equipment and supplies
- Prevent transmission to patients and HCWs
- Triage and early detection
- Implementation of infection control measures
- Coordinate with other healthcare settings and health department

## 556 hospitals in 47 states and Puerto Rico completed a survey on hospital preparedness 
Many hospitals had SARS plans but few had coordinated them with other facilities or jurisdictions
Infection control and certain specialty services were limited in small and rural hospitals
The number of negative pressure rooms and other medical equipment/supplies may not be adequate for a large event

- Many hospitals had SARS plans but few had coordinated them with other facilities or jurisdictions
- Infection control and certain specialty services were limited in small and rural hospitals
- The number of negative pressure rooms and other medical equipment/supplies may not be adequate for a large event

**Assessment of Hospital Preparedness for Emerging Infectious Disease Threats**

**Notes:**
Read slide

## Proportion of Hospitals Lacking Infection Control Workforce by Bedsize

-                                                              Bed size
- 	_<100_	_100-299_	_300-499_	_≥500_
- 	N=224	N-142	N=154	N=32
- Infection Control 	  44 (20)	     7  (5)	    3   (2)	0
- Practitioner
- Hospital	215 (96)	114 (80)	109 (71)	11 (34)
- Epidemiologist
- ID Physician	186 (83)	  79 (56)	  45 (29)	0
- Occupational Health	180 (80)	  91 (64)	  83 (54)	  6 (19)
- Physician
- Occupational Health	110 (49)	  37 (26)	    9  (6)	  1   (3)
- Nurse

**Notes:**
As you can see the proportion of hospitals lacking these members of the workforce decreased as bed size increased.  
The proportion of hospitals lacking ICP FTE’s ranged from  20% among hospital’s <100 beds to 0% among those with ≥500 beds.
Lacking HE FTE 86%<100 beds, to 34%  in >=500 beds
Lacking ID FTE 83% to O
Lacking OHP FTE 80 – 19%
Lacking OHN FTE  49 – 3%
Of note is the lack of ICP’s and HE’s in hospitals ≥300 beds.  
The lack of occupational health personnel in each strata may be overrepresented as some of the hospitals may have contracted services that are not counted as FTE’s.

(note: children’s hospitals were more likely to have a HE)

## US Hospitals by Bed Size

| Hospital Bed Size | Number of Hospitals | Percent |
| --- | --- | --- |
| <100 | 2922 | 48.6 |
| 100-199 | 1426 | 23.7 |
| 200-499 | 1339 | 22.3 |
| >=500 |   326 |   5.4 |
| Total | 6013 | 100.0 |

- Source: AHA Annual Survey 2002

## Results of APIC Influenza Survey2003/2004 Season

- Shortages
- Diagnostic kits (50+%)
- Staffing (35%)
- Vaccine (25%)
- Beds (28%)
- Diversions averaging 6 days in 9% of facilities
- HCW vaccination rate of 50%
- Respiratory hygiene program consistent with CDC/HICPAC recommendations implemented in 81%

## Field Exercises - Observations

- Lack of adherence to proper infection control practices and confusion about PPE use
- Inadequate planning for
- exposure management of healthcare workers
- surge capacity including staff, beds, equipment, and laboratory services
- Inadequate healthcare staff with appropriate expertise during non-peak hours
- Unclear notification and communication channels internally and externally

## Participants

- WHO
- HHS (CDC, HRSA)
- State and local health departments
- Hospitals
- Emergency responders
- Professional organizations
- Providers

## WHO Plan:  New Phases

- Interpandemic
- Phase 1:  no new subtypes in humans; subtype in animals with low risk of human infection
- Phase 2:  no new subtypes in humans; subtype in animals with substantial risk of human disease
- Pandemic alert
- Phase 3:  human infections with new subtype; no or rare human-to-human spread
- Phase 4:  small clusters of human-to-human transmission
- Phase 5:  large clusters of human-to-human, but localized
- Pandemic period
- Phase 6:  sustained transmission
- Postpandemic period

- _www.who.int/csr/disease/influenza/inforesources/en/_

## HHS Plan: Healthcare and Emergency Response 

- Inter-Pandemic Phase (Phase 0, level 1 and 2)
- Assess capacity of healthcare and emergency response system to meet needs in a pandemic (ASPHEP)
- Inter-Pandemic Phase (Phase 0, level 3)
- Review and revise plans for healthcare delivery and community support (HHS, HRSA)
- Assess availability of personnel, supplies and materials for infection control and clinical care of infected patients should a pandemic occur (HRSA)
- Disseminate infection control guidelines to hospitals, long-term care facilities, and medical care providers (HRSA, CDC)

## HHS Plan: Healthcare and Emergency Response

- Pandemic confirmed (Phase 1)
- Activate state and local plans to coordinate healthcare delivery and community response (ASPHEP, HRSA)
- Pandemic spreading (Phase 2)
- Establish inpatient medical care in non-traditional facilities to provide hospital bed surge capacity (HRSA)
- Assess quality of healthcare and emergency response (HRSA)
- End of first wave (Phase 3)
- Assess effectiveness of healthcare and service delivery during prior phases and revise as needed (ASPHEP)

## HRSA Cooperative AgreementCritical Benchmarks

- Must be achieved by August 31, 2007
- Establish a system for triage, treatment, and initial stabilization of 500 adult and pediatric patients per 1,000,000 above current capacity
- Ensure all participating hospitals can maintain at least one case of a highly infectious disease in negative pressure isolation and have at least on regional facility that can support the initial evaluation and treatment of at least 10 patients at a time in negative pressure isolation

## HRSA Cooperative AgreementCritical Benchmarks

- Establish as system for immediate deployment of additional HCWs in support of surge bed capacity
- Develop a system for advance registration and credentialing of clinicians needed for surge capacity
- Establish regional plans to insure supply of prophylaxis meds for 3 days (HCWs and community)
- Ensure adequate PPE for surge capacity staff
- Ensure adequate decontamination systems
- Enhance capacity of care related to behavioral health consequences

## HRSA Cooperative AgreementCritical Benchmarks

- Cross-cutting benchmark:  Preparedness for Pandemic Influenza
- Describe current plan for response
- Provide a complete plan (summer 2005)

## CDC Division of Healthcare Quality Promotion

- Infection control guidance (HICPAC)
- Evaluation of prevention measures
- Investigation of healthcare-associated outbreaks
- Established networks with hospitals
- Long-standing partnerships (APIC, SHEA, AHA)
- Monitoring adverse events (antivirals with FDA)
- Healthcare and Infection Control supplement for CDC plan

## CDC Plan

- Preparedness Planning for Hospitals
- Disease surveillance
- Hospital communications
- Education and training
- Triage and admissions
- Facility access
- Occupational health
- Vaccine and antiviral use and adminstration
- Surge capacity
- Mortuary issues

## CDC Plan

- Preparedness planning for non-hospital settings
- Infection control recommendations for hospitals and non-hospital settings
- Infection Control Supplement
- Hospital Preparedness Checklist
- Tabletop exercises

## Slide 24

| WHO | HHS | CDC |
| --- | --- | --- |
| Infection control
Health facilities
Health personnel
Health supplies
Excess mortality | Decision making and coordination
Surveillance
Triage and clinical evaluation
Human and physical resources
Education, training, and communication
Antivirals and vaccine
Infection Control 
Outbreak control
Nontraditional sites | Disease surveillance
Hospital communications
Education and training
Triage and admissions
Facility access
Occupational health
Vaccine and antiviral use
Surge capacity
Mortuary issues
Infection control |

## Issues

- Coordination
- Surge capacity
- Alternative care sites
- Planning and implementation tools
- Mask and respirator recommendations
- Preparing the public (expectations)
- Monitoring progress

## Coordination

- How to facilitate coordination of planning efforts? (consistency of recommendations and efficient use of resources)
- At national, state, and local levels?
- Between public health and healthcare systems?
- Among healthcare systems?
- With other planning activities? (SARS)
- What else needs to be done?
- How can it be implemented?

## Surge Capacity

- What is the true capacity for increasing the number of available HCWs? (e.g., available number of administrators with clinical competence, volunteers)
- What are the barriers using volunteers? How can they be addressed?
- Should the focus be on efficient use of current resources?

## Alternative Care Sites

- What federal sites are available nationwide?
- How well are states doing in assessing availability of other sites?
- What tools are available for assessing requirements?

## Tools

- What tools are available to assist healthcare facilities and health departments in planning and implementation?
- Use existing tools (e.g., FluSurge, guideines)
- Identify other tools that can be adapted
- Which ones are priority for development?

## Examples of Tools

- Tracking systems (staffing, beds, flow of care, supplies, etc.)
- Triage algorithms
- Hotline templates
- System for detecting transmission in the hospital
- Public education tools
- Templates for daily reports and other communication tools
- Emergency training materials for volunteers
- Protocols to prioritize procedures, limit elective admissions
- Staffing priority groups
- Consumable resource needs
- Vaccine and antiviral distribution models
- Description of field hospital requirements

## WHO Plan: Measures to Reduce Risk of Transmission

- Confinement
- plan for large numbers
- type not specified
- Face masks
- Symptomatic persons – surgical mask
- Exposed persons
- Consider use and type based on risk assessment
- N95 for HCWs
- Public places:  permitted but not encouraged

## Respirators and Masks

- Influenza recommendations
- Standard and droplet precautions
- Surgical mask for HCWs
- Private room
- Avian influenza recommendations
- Airborne isolation
- N95 for healthcare workers
- Airborne isolation room (negative pressure)
- Pandemic influenza
- WHO plan implies N95 for HCWs
- Graded response? (maximum precautions early for containment but not feasible later)
- Use in public places (permit but not encourage?)

## Preparing the Public

- How do we best prepare the public?
- Stay home when sick
- Respiratory hygiene and cough etiquette
- Telephone triage

## Monitoring Progress

- How to prioritize preparedness activities (limited resources)?
- How to monitor progress toward readiness?
- Benchmarks
- Timelines
- Testing
- Coordination

## NVAC Pandemic Preparedness Work Group

- Facilitate coordination
- Review and provide input on guidance
- Unresolved issues
- Surge capacity
- Alternative care sites
- Assess barriers to implementation
- Identify existing tools and other resources
- Prioritize needs
- Monitor progress

## Healthcare Preparedness for Pandemic

- Impact of previous pandemics
- Inter-pandemic preparedness planning
- Surveillance
- Capacity and supplies
- Communication and Education
- Lessons learned from SARS

##     Timeline of Emergence of 

- Influenza Viruses in Humans

**1918**

**1957**

**1968**

**1977**

**1997**

**1998/9**

**2003**

**H1**

**H1**

**B**

**H2**

**H7**

**H5**

**H5**

**H9**

**Spanish**
**Influenza**

**Asian**
**Influenza**

**Russian**
**Influenza**

**Avian**
**Influenza**

**Hong Kong**
**Influenza**

**H3**

**Pandemic**
**vaccines**

**Regular vaccines**

## Pandemic Spread

- Spread of pandemic
- Months to reach U.S. of prior pandemic strains 1918- 0; 1957 – 2-3; 1968 – 2-3 ; 1977 – 3-4
- International travel---Globalization

## Impact of Previous Pandemics

- Spanish flu 1918-19: killed 20-40 million people, 675,000 in the United States.
- Asian flu (57-58) and Hong Kong flu (68-69) killed a total of 103,600 people in the United States.
- Annual influenza epidemics cause 36,000 deaths and 226,000 hospitalizations in the United States.

## Previous Pandemics

- Besides the elderly, excess of mortality is also likely in younger adults and children
- 1918/19 higher mortality in younger adults and children
- 1957 higher mortality in older adults
- 1968/69 higher mortality in children and older adults
- In planning, consider several scenarios based on clinical attack rates, case fatality rate etc.

## Estimated Number of Cases by Outcome, Attack Rate of 15%, Canada

| Outcome | Mean number | 5th 
Percentile | 95th Percentile |
| --- | --- | --- | --- |
| Death | 17,768 | 10,544 | 24,954 |
| Hospitalization | 46,639 | 34,042 | 59,166 |
| Outpatient care | 2,086,327 | 2,027,496 | 2,145,282 |
| Ill, no formal care | 2,394,443 | 2,335,458 | 2,455,967 |
| Total | 4,545,177 | 4,407,545 | 4,685,464 |

- Source: Canadian Pandemic Influenza Plan

## Healthcare Preparedness for Pandemic

- Impact of previous pandemics
- Inter-pandemic preparedness planning
- Surveillance
- Capacity and supplies
- Communication and Education
- Lessons learned from SARS

## Inter-Pandemic Preparedness for Hospitals

- _Objective:_ develop planning and decision-making structures for responding effectively to pandemic influenza
- Create and test a plan that provides efficient and effective healthcare to influenza-infected patients and minimizes the disruption of other healthcare delivery
- Build partnerships with state and local health departments, local and/or regional healthcare facilities

## Inter-Pandemic Planning

- Facilitate awareness of the potential impact of a pandemic on the healthcare system
- Prepare resources and guidelines that may be adapted during pandemic (clinicians, patients, and family members)
- Educate and train healthcare personnel to detect patients with influenza, support surveillance systems, and manage and treat patients

## Disease Surveillance 

- Establish a system to detect cases and relay information to local and/or state health departments
- Surveillance for ILI in ER and outpatient settings
- System for internal review of pandemic influenza activity in patients to the emergency department
- Laboratory surveillance for unusual isolates
- System to detect transmission in the institution
- Test plan using non-pandemic influenza as a surrogate agent

## Assess Your Capacity

- Assess bed and ventilator capacity
- Assess supply needs for consumable  resources (e.g., PPE)
- Assess morgue capacity
- Prepare for airborne isolation
- Mobilize required resources (e.g., medical, emergency response) within respective jurisdiction

## Prioritize Beds

- Spectrum of illness is broad, ranging from asymptomatic infections to death -- Be prepared for complications
- Develop criteria and plans for limiting access to the healthcare facility during a pandemic
- Prioritize elective medical and surgical admissions
- Develop policies and procedures for expediting discharge of patients who do not require inpatient care

## Community Coordination

- Coordinate and develop agreements with other facilities in the community/ region
- Health departments
- Home health care
- Long term care
- Primary care

## Emergency Services and Triage

- Emergency services
- Encourage collaboration between emergency service personnel and public health authorities
- Facilitate continuous state of readiness through ongoing educations, testing, revision of plans
- Triage and clinical evaluation of patients
- Develop and test options for triage during peak of pandemic

## Respiratory Hygiene/Cough Etiquette

- Universal strategy for patients with symptoms of respiratory infection at initial point of contact with healthcare system
- Visual alerts
- Tissues or surgical masks for patients
- Hand hygiene materials in waiting areas
- Physical separation of patients with febrile respiratory illnesses
- Masks for healthcare workers caring for febrile respiratory patients and use Droplet precautions

## Staffing Issues

- Plan on what to do when the healthcare system is overwhelmed and care must be provided by persons doing work which is normally not part of their daily activities
- Develop strategies to meet the range of staffing needs (e.g., recruit retired healthcare personnel)
- Engage clinicians in flu-related activities (e.g., provide data from ILI surveillance)
- Psychological support to healthcare workers

## Education

- Clinicians and other healthcare professionals
- diagnosis and treatment
- prevention of transmission
- Patients and family members
- respiratory hygiene
- when to go to the hospital

## Communication Plan

- Establish rapid and ongoing communication with
- public health officials
- other healthcare facilities,
- lay public and press
- public officials
- Ensure that a system is in place for timely communication about pandemic influenza within the healthcare facility
- Develop and test a plan to communicate/educate patients and visitors to avoid the hospital

## Vaccination and Antiviral Use

- Plan to use (and distribute) antiviral agents for prophylaxis and treatment
- Healthcare personnel
- Patients and family members
- Plan to prioritize the use of vaccines
- Develop a system to monitor
- Work with local and state health department
- Promote vaccination during inter-pandemic period

## Test the System

## Healthcare Preparedness for Pandemic

- Impact of previous pandemics
- Inter-pandemic preparedness planning
- Surveillance
- Capacity and supplies
- Communication and Education
- Lessons learned from SARS

## Lessons from SARS

- Early detection is vital
- Healthcare personnel resources can be affected by illness, fatigue, and fear
- Infection control also requires attention to visitors and family members
- Education and training with regular updates are necessary
- Clear chains of decision making and communication are needed

## 556 hospitals in 47 states and Puerto Rico completed a survey on hospital preparedness 
Many hospitals have SARS plans but few have coordinated them with other facilities or jurisdictions
Infection control and certain specialty services are limited in small and rural hospitals
The number of negative pressure rooms and other medical equipment/supplies may not be adequate for a large event

- Many hospitals have SARS plans but few have coordinated them with other facilities or jurisdictions
- Infection control and certain specialty services are limited in small and rural hospitals
- The number of negative pressure rooms and other medical equipment/supplies may not be adequate for a large event

**Assessment of Hospital Preparedness for Emerging Infectious Disease Threats**

**Notes:**
Read slide

## Proportion of Hospitals Lacking Infection Control Workforce by Bedsize

-                                                              Bed size
- 	_<100_	_100-299_	_300-499_	_≥500_
- 	N=224	N-142	N=154	N=32
- Infection Control 	  44 (20)	     7  (5)	    3   (2)	0
- Practitioner
- Hospital	215 (96)	114 (80)	109 (71)	11 (34)
- Epidemiologist
- ID Physician	186 (83)	  79 (56)	  45 (29)	0
- Occupational Health	180 (80)	  91 (64)	  83 (54)	  6 (19)
- Physician
- Occupational Health	110 (49)	  37 (26)	    9  (6)	  1   (3)
- Nurse

**Notes:**
As you can see the proportion of hospitals lacking these members of the workforce decreased as bed size increased.  
The proportion of hospitals lacking ICP FTE’s ranged from  20% among hospital’s <100 beds to 0% among those with ≥500 beds.
Lacking HE FTE 86%<100 beds, to 34%  in >=500 beds
Lacking ID FTE 83% to O
Lacking OHP FTE 80 – 19%
Lacking OHN FTE  49 – 3%
Of note is the lack of ICP’s and HE’s in hospitals ≥300 beds.  
The lack of occupational health personnel in each strata may be overrepresented as some of the hospitals may have contracted services that are not counted as FTE’s.

(note: children’s hospitals were more likely to have a HE)

## US Hospitals by Bed Size

| Hospital Bed Size | Number of Hospitals | Percent |
| --- | --- | --- |
| <100 | 2922 | 48.6 |
| 100-199 | 1426 | 23.7 |
| 200-499 | 1339 | 22.3 |
| >=500 |   326 |   5.4 |
| Total | 6013 | 100.0 |

- Source: AHA Annual Survey 2002

## Smallpox and SARS Field Exercises

- Purpose: to identify operational, logistical, communication, and administrative needs to prepare and manage BT or epidemic events
- Participants:
- Airlines
- Local law enforcement, EMS, emergency planners
- Local and state public health departments
- Local healthcare facilities
- Custom and Border Patrol, Port Authority, TSA, DHS, and CDC

## Field Exercises - Observations

- Lack of adherence to proper infection control practices and confusion about PPE use
- Inadequate planning for:
- exposure management of healthcare workers
- surge capacity including staff, beds, equipment, and laboratory services
- Inadequate healthcare staff with appropriate expertise during non-peak hours
- Unclear notification and communication channels internally and externally

## Conclusion

- Several actions can be taken to better prepare for pandemic influenza
- We need to use lessons learned from SARS response and examples from previous pandemics to improve preparedness for pandemic influenza
- Test the system – individual and regional – will help to identify gaps that can be addressed in the inter-pandemic period

- _Hurry Up and Get Ready!!!_

## PREVENTION  IS PRIMARY!

*Protect patients...protect healthcare personnel...*
*promote quality healthcare!*
- Division of Healthcare Quality Promotion

## Distribution of Respondents, Hospital

- 21-30
- 11-20
- 1-10
- 0

**Distribution of Respondents, Hospital**
**Preparedness Assessment,**
**N=556**

**Notes:**
A total of 556 (45%) hospitals responded.

The respondents from were from 47 states and Puerto Rico.  The number of hospitals responding ranged from one to ≥≥30 in California, Texas, Florida, and Pennsylvania.

There were no respondents from Maine, Rhode Island, or Wyoming.

## Healthcare Planning and Preparedness Needs

- Surge capacity – staff, beds, supplies, equipment
- Regional coordination/collaboration
- Triage
- Infection control
- Delivery of interventions to staff and patients

## Marburg Virus Hemorrhagic Fever

- Angola, October 2004- April 5th, 2005
- Total of 163 cases, 150 fatal
- 75% of reported cases in children aged <5 years
- Healthcare workers
- Predominant symptoms: fever, hemorrhage, maculopapular rash, vomiting, cough, diarrhea, and jaundice

## Act Now!Address Prevention Planning Priorities in Emergency Departments, Outpatient Offices, and Inpatient Units

## Pandemic Period: New Virus Transmitted Person-to-Person Abroad

- _Objective_: Heighten institutional surveillance for influenza and prepare to activate institutional pandemic influenza plans
- Collaborate with key partners on planning preparations
- Heighten surveillance
- Reinforce basic infection control measures to prevent spread of influenza
- Accelerate training

## Pandemic Period: Virus Transmitted Person-to-Person in United States 

- _Objective_: Maintain integrity of healthcare delivery services while responding to the community’s need for quality care
- Rapidly identify, isolate, and treat all patients with potential pandemic influenza
- Continue to provide healthcare by implementing system to increase capacities
- Maintain rapid and frequent communication within and among healthcare facilities and with state and local health departments to optimize response and control efforts.

## Influenza vs. SARS

|  | Influenza | SARS |
| --- | --- | --- |
| Incubation period | 2-4 days |  4-10 days |
| Infectious period | Average: 5 days
Maximum: ------- | Average: ------
Maximum:-------- |
| Age distribution | Children / unknown | Adults |
| Mode of transmission | Droplet > airborne | Droplet >> airborne |
| Symptoms & infectiousness | Parallel. May be infectious when not ill. | Parallel. Not infectious when not ill |

## Lessons Learned

- Communication
- Compliance with basic infection control
- Leadership support
- Clinicians engagement
- Collaboration with community and public health planning groups
- Globalization

## Surveillance Plan: during pandemic

- Monitor morbidity and mortality associated with pandemic
- Determining if transmission is occurring in the facility – potential breaches of infection control

## Infection control is EVERYONE’s responsibility!

## Lessons Learned from SARS (1)

- Transmission risks are primarily from:
_**Unprotected exposures to**_ _**unrecognized cases**_ in both inpatient and outpatient settings.
- We must look beyond the patient ... contacts may be infectious too.
- Prevention begins when a patient or visitor walks through the door of an Emergency Department or outpatient office.

## Lessons Learned form SARS (2)

- Use of PPE prevents transmission...however,
- Healthcare personnel need instruction on how to don, use and remove PPE
- Wearing PPE for extended periods of time is a burden and can lead to breaches in technique

## Education and Training Plan

- Clinical personnel should be educated about influenza disease, diagnosis and management
- Highlight the importance of vaccination
- Educate all facility and patients, family members and visitors about the prevention and control
- Triage and clinical evaluation of patients

## When in North America?

- Canada – within 3 months after it emerges in another part of the world
- Spreads in 2 or more waves – 3-9 months of initial outbreak

## Is a Pandemic Imminent?

- New influenza A virus arising from a major genetic change
- Susceptible population with little or no immunity
- Virus transmitted efficiently from person-to-person
- Virulent virus with capacity to cause serious illness and death

## Factors Increasing Concern

- H5N1 has infected mammals (humans, cats, and pigs)
- The influenza season (H3N2) in northern Vietnam is ongoing concurrent with avian influenza
- Endemic H5N1 in ducks and wild birds makes eradication of this strain unlikely
- Antigenic change continues to occur

## Assessment of Hospital Preparedness for Emerging Infectious Disease Threats

- GAO survey suggested urban hospitals are ill prepared for a major biologic event
- SARS pandemic highlighted
- Importance of infection control programs and workforce
- Need for adequate equipment and supplies

## Preparedness Planning: Healthcare

- Preparedness Plan Elements
- Organizational infrastructure
- Logistics of patient care
- Staffing
- Durable and consumable resources
- Exposure management
- Patient focused pre-event planning
- Fix the weaknesses in the system

## Creating the Organizational Infrastructure

- Multi-disciplinary team
- Scientific leadership – healthcare epidemiology/infection control
- Administrative leadership
- Clinical representation
- Engineering/Environmental Services
- Communications/public relations
- Safety/security
- Other

## Respiratory Hygiene/Cough Etiquette

- Universal strategy for patients with symptoms of respiratory infection at initial point of contact with healthcare system
- Visual alerts
- Tissues or surgical masks for patients
- Hand hygiene materials in waiting areas
- Physical separation of patients with febrile respiratory illnesses
- Masks for healthcare workers caring for febrile respiratory patients and use Droplet precautions

## APIC Influenza Survey

- Assess the impact of the 2003/2004 influenza season on healthcare facility resources
- Assess adoption of respiratory hygiene programs

## Availability of Preparedness Plans

- 		N (%)
-  Written SARS plan	320 (58)
- Coordination of plan with:
- 	   local heath department	247 (77)
-   healthcare facilities	175 (55)
-   municipalities	 85 (27)

**Notes:**

58% of hospitals reported having a written SARS plan.
(Note if asked: hospitals <100 beds and rural  less likely to have a plan, p = <.001 for both)

77% of hospitals reported that they  had a written SARS plan that was also coordinated with local health departments, 55% had coordinated their plans with other hospitals, and 27% had coordinated their plans with a multi-county or state team.

## Workforce Resources

- 	_Total_	_Urban_	_Rural_	_p-value_
- 	(%)	(%)	(%)
- Microbiologist	65	78	41	<.0001
- Pulmonologist	65	84	30	<.0001
- Mental Health	61	71	42	<.0001
- Counselor
- Health Communicator	77	87	60	<.0001
- Bioterrorism	76	77	72	.1
- Coordinator

**Notes:**
We also examined the IC workforce and the availability of other personnel who may be involved in a hospital’s response to a BT or EID event
12% of hospitals lacked any ICP FTE’s,  the median number of FTE’s at all hospitals was 1 with a range of 0-10.
81% lacked any hospital epidemiologist FTE’s, median of 0 and a range of 1-5.
56% lacked any ID physician FTE’s , median of 0 and a range of 0-17.
65% lacked any Occupational Health Physician FTE, median of 0 and a range of 0-5
29% of hospitals lacked any Occupational Health Nurse FTE, with a  median of 1FTE and a range of 0-15.

Medians are zero as the data are skewed.

## Proportion of Hospitals Lacking Infection Control Workforce by Bedsize

-                                                              Bed size
- 	_<100_	_100-299_	_300-499_	_≥500_
- 	N=224	N-142	N=154	N=32
- Infection Control 	  44 (20)	     7  (5)	    3   (2)	0
- Practitioner
- Hospital	215 (96)	114 (80)	109 (71)	11 (34)
- Epidemiologist
- ID Physician	186 (83)	  79 (56)	  45 (29)	0
- Occupational Health	180 (80)	  91 (64)	  83 (54)	  6 (19)
- Physician
- Occupational Health	110 (49)	  37 (26)	    9  (6)	  1   (3)
- Nurse

**Notes:**
As you can see the proportion of hospitals lacking these members of the workforce decreased as bed size increased.  
The proportion of hospitals lacking ICP FTE’s ranged from  20% among hospital’s <100 beds to 0% among those with ≥500 beds.
Lacking HE FTE 86%<100 beds, to 34%  in >=500 beds
Lacking ID FTE 83% to O
Lacking OHP FTE 80 – 19%
Lacking OHN FTE  49 – 3%
Of note is the lack of ICP’s and HE’s in hospitals ≥300 beds.  
The lack of occupational health personnel in each strata may be overrepresented as some of the hospitals may have contracted services that are not counted as FTE’s.

(note: children’s hospitals were more likely to have a HE)

## Equipment Resources

- 	_Total_	_Urban_	_Rural_	    _p-value_
- 	(%)	(%)	(%)
- ≥1 NPR on wards	86	92	75	   <.0001
- ≥1 NPR in ICU	64	79	38	   <.0001
- ≥1 NPR in ER	57	72	33	    <.0001
- ability to create NPR	34	37	28	  .03
- ≥1 mechanical ventilator	91	95	84	      .0003
- ≥1 portable HEPA filter	51	55	45	  .02
- ≥1 portable x-ray machine	97	98	98	.5
- NPR = negative pressure room

**Notes:**
overall (read totals) then compare urban and rural

Rural hospitals were less likely to have at least one negative pressure room on their wards or in their ICUs or ERs. They were also less likely to have the ability to create  negative pressure rooms, have at least one mechanical ventilator or portable HEPA filter,  but are as likely as urban hospitals to have portable x-ray machines.

## Workforce Resources

- _Occupation_	_None_	_Median FTE_	_Range_
- Infection Control	12%	1	  0 - 10
- Practitioner
- Hospital	81%	0.0	0 – 5
- Epidemiologist
- ID Physician	56%	0.0	  0 – 17
- Occupational Health	65%	0.0	0 – 5
- Physician
- Occupational Health	29%	1	  0 – 15
- Nurse

**Notes:**
We also examined the IC workforce and the availability of other personnel who may be involved in a hospital’s response to a BT or EID event
12% of hospitals lacked any ICP FTE’s,  the median number of FTE’s at all hospitals was 1 with a range of 0-10.
81% lacked any hospital epidemiologist FTE’s, median of 0 and a range of 1-5.
56% lacked any ID physician FTE’s , median of 0 and a range of 0-17.
65% lacked any Occupational Health Physician FTE, median of 0 and a range of 0-5
29% of hospitals lacked any Occupational Health Nurse FTE, with a  median of 1FTE and a range of 0-15.

Medians are zero as the data are skewed.

## Other Healthcare Settings

- Criteria for readmission
- Of one case, assume all are exposed:
- Cancel or postpone procedures
- Coughing residents stay in their rooms

## Smallpox and SARS Field Exercises

- Purpose: to identify operational, logistical, communication, and administrative needs to prepare and manage BT or epidemic events
- Participants:
- Airlines
- Local law enforcement, EMS, emergency planners
- Local and state public health departments
- Local healthcare facilities
- Custom and Border Patrol, Port Authority, TSA, DHS, and CDC