Symposium on Pandemic Influenza - October 2007
By Mary Katherine Sanchez, DrPH, and Elvin Adams, MD, MPH
The potential for the emergence of a pandemic has been heightened by scattered human infections with the highly pathogenic Asian strain of avian influenza A H5N1. 1 A pandemic among humans would infect large numbers of citizens, resulting in a demand for acute health care that would far exceed the capacity of local hospitals. In such a situation, the application of carefully prepared triage protocols could provide public health departments, regulatory agencies, and health care institutions with a strategy to optimize resource utilization and assure the public that the health care system is operating in a way to preserve the greatest number of lives.
While the severity of the pandemic caused by a specific organism cannot be accurately predicted, evidence from previous historical pandemics reveals that many individuals who become ill could survive, even without hospital or advanced medical care. In 1918, the overall mortality of the Spanish flu pandemic was just over 2 per cent, meaning that 98 per cent of those who became ill with the disease survived. 2
A new pandemic infecting 30 percent or 40 percent of the population with a similarly low mortality rate would result in large numbers of patients unnecessarily seeking hospitalization and acute medical care. If this occurs, layers of triage at multiple points in the path leading to hospitalization may be necessary. Effective triage and patient management during a pandemic is not a simple process conducted in the emergency department of the local hospital. Successful triage is a continuing mechanism that should occur at multiple points outside the hospital by using the media, nonmedical communicators, emergency medical services (EMS) personnel, public health officials, elected officials, and police and fire departments, as well as doctors and nurses. Local public health officials would take a leadership role in establishing a stepped system of triage as the number of people with symptoms increases and reports of deaths occurring at home multiply. Many individuals may seek hospitalization in spite of knowing that hospitals are able to admit and care for only a few new patients each day. This situation will require multipronged triage efforts aimed at keeping at home or returning to home most of the sick.
Throughout history, alternative care facilities have been established to assist hospitals and communities by serving as triage stations, caring for the "walking wounded," and even serving as locations to provide patient care when health care facilities are unable to do so. 3 However, in the case of an influenza pandemic, the U.S. Department of Health and Human Services (HHS) and the White House Homeland Security Council estimate that up to 10 per cent of the community's population could be ill at the same time, 4 while others will be off work caring for ill family members. Still others will choose to stay home, hoping to avoid getting sick. Events like this will further depress staffing capabilities at health care institutions and businesses. This would result in approximately 30 per cent of the workforce population staying at home; therefore, there will likely be a shortage of medical personnel and staff to run a full-scale alternative care clinic, 3 creating a greater need for an effective and multitiered triage system designed to keep people at home and away from hospitals.
If hospitals are at maximum capacity, health care and the treatment of the ill at home by family members may become the only remaining realistic option for managing ill patients. Educational efforts should be directed toward teaching patients and their family members how best to provide care for the sick at home.
The first level of triage should be provided by regular and up-to-date announcements by local health officials. This information should include the status of available resources (including hospital beds), where to seek medical care, and what clinical symptoms should prompt someone to seek care. Information should emphasize also the importance of maintaining adequate hydration and the control of symptoms with over-the-counter (OTC) medications. Instructions on how to protect healthy family members from those who are ill in the household should also be given.
Such measures and guidance documents are being undertaken by the American Red Cross, local health departments, and the U.S. Centers for Disease Control and Prevention. 5
Individuals can best be prepared for a pandemic by preplanning. Having a plan, storing a supply of food, stocking some OTC medications for control of flu symptoms, and having a communication strategy with family members and work colleagues represent a personal response to the first level of triage. A complete checklist can be found online at http://www.flu.gov/individualfamily/about/pandemic/index.html.
With frequent announcements and clear guidance for individuals and families at home, health care professionals hope to lessen the burden of overcrowding on hospitals. For example, during the SARS (severe acute respiratory syndrome) restriction periods in Toronto, the rate of overall and medical admissions decreased by 10 percent to 20 percent, 6 the rates of elective cardiac procedures declined by 66 percent in Toronto and by 71 percent in comparison regions, high-acuity emergency room visits declined by 37 percent, and interhospital patient transfers declined by 44 per cent in the Toronto area. 4
The second level of triage could be provided by call centers and phone banks. This is a critical triage step and will be effective only with adequate surge capacity in lines and personnel. A failure of phone communication can contribute to panic and result in a run on hospital triage centers. Lessons can be learned from the communication breakdown that occurred in Toronto during the SARS outbreak. The problem was described in a 2004 report by the SARS Commission. 7 A major cause of the breakdown was due to a lack of effective methods for rapidly increasing phone capacity. For example, phones were staffed by more than 200 people, and the hotline received more than 300,000 calls. During the peak, 47,567 calls were received in just one day.
Local communication infrastructure should be examined and improved so that consistent, up-to-date information can be disseminated by persons better prepared to respond to the surge of calls that will inevitably be seen during a pandemic. This problem has been succinctly described, and innovative solutions have been suggested by a group of students at Stanford. 8 No national hotline has been set up for the specific purpose of providing information in the event of a pandemic. Local hotlines have a limited capacity.
The Stanford students propose that callers be first served by an automated answering system that could provide and obtain basic information. The call would then be directed to a bank of nonprofessional volunteers for general information. This nonmedical staff would dispense advice following prepared protocols for simple questions. Emergency situations could be shunted by the answering system directly to medical experts who would answer more complex questions passed on by the volunteers.
Instructions could be given on whether sick patients need further medical care, how to prevent additional cases in the home, how to care for a patient at home, and where to obtain necessary medical supplies. Telephone triage would not only allow patients to obtain guidance from health care professionals without risk of exposure, but would also allow for critical patients to be sent to designated facilities with known resources.
A 2003 evaluation of telephone triage concluded that in detecting influenza-like illnesses, telephone triage is a promising data source for use in public health surveillance. 9 The study even suggests that with emergency room telephone triage, a system where individuals were encouraged to call and be triaged over the telephone before reporting to the emergency room, data collection was timelier than currently collected influenza surveillance data. 9
The third level of triage could be provided by 911 operators and EMS personnel. EMS personnel who respond to calls could assess ill patients and determine if transport is indicated. The decision as to whether to transport ill patients would require protocols to be drafted by EMS medical directors. Such protocols have yet to be written. 10 During a pandemic when demand for services will be high, EMS may no longer respond to calls regarding a cardiac arrest at home and should not respond to a flu-related death.
EMS personnel could also provide expanded ambulatory care, a concept built on the premise that "a system of effective outpatient management may reduce the demand for inpatient services." 11 Services such as hydration and medication distribution could be done through EMS personnel on site as they respond to a call. This would limit exposure as well as eliminate the need for an outpatient clinic.
Expanded ambulatory care may also be provided at outpatient sites (for example, pandemic influenza plans from New Jersey and Ohio recommend expanded ambulatory care for patients to "receive hydration, intravenous antibiotics, or monitoring" at "short stay" outpatient sites 12 ).
The fourth level of triage could occur at the hospital. Individual emergency departments would establish triage facilities to manage large volumes of patients. To minimize exposure of hospital personnel and to allow the screening of large numbers of patients, primary triage sites would be physically separate but located near the hospital emergency department. All patients with influenza-like illness who insisted on being seen at a medical facility would be directed to these centers for assessment and triage. Critical patients would be transferred to the hospital for care, if beds and resources are available. Some patients may be transferred to facilities that provide a less acute level of patient care such as assisted living facilities. Noncritical patients would be discharged home with guidance and care instructions and medication for symptoms if available. 2
Hong Kong has adopted this model by planning to "set up designated clinics and protocol for triaging patients with influenza-like illness at the primary care level … [and] isolate and treat confined cases in designated hospitals." 13 Without such a centralized protocol or system in place, hospitals will be left to independently determine triage systems on the basis of their own available resources, personnel, and patient numbers.
In a pandemic, when the hospital is already full, most of those seen at a hospital triage center will need to be sent home with instructions on how to care for themselves. The instructions should be the same as the messages provided at other levels of triage.
Security issues will be most critical at hospital triage sites. Those seeking care may become unruly, especially if significant time delays are seen and if patients are triaged to go home. It may be difficult to obtain expanded security services if the security force itself is depleted because of sickness.
Some patients who elect to be cared for at home or who are triaged to home care by the phone bank, EMS, or hospital will eventually die at home. This will include many who have comorbidities that decrease the likelihood of survival, as well as those who develop septic complications or who are simply overwhelmed by the virus. Education should be provided at all triage levels on what to do should a death occur at home. This process can be simplified if the patient and a physician sign a "Do Not Resuscitate" (DNR) form as the patient is sent home. Because death can be anticipated in many cases, the family should make a list of important telephone numbers to be used when a patient dies. This list should include numbers for the family physician, home health agency, hospice, clergy, funeral director, family lawyer, executor, bank, and others.
If a person dies at home during a pandemic, EMS should not be called. Funeral homes and such services could be called directly during a pandemic. The medical examiner could coordinate directly with funeral homes regarding the causes of death and preparation of death certificates. Details on how to prepare for a death at home are outlined online at www.gov.ns.ca/health/downloads/preparing_at_home.pdf .
Who would organize such a triage system as described above? Planning by public and private institutions is required. Hospitals are potentially the institutions to be most severely stressed by a pandemic, but all health care institutions, EMS, home health agencies, hospices, private physicians, medical societies, and pharmacies need to be involved. The best Web site for all agencies to consult for help in planning is www.pandemicflu.gov. Leadership in coordinating triage efforts would fall to local public health officials, with support from local government, police, and fire officials. Public health officials will be able to do little unless planning has taken place before the crisis occurs. Networking now with all groups and agencies with an eye open toward a coming pandemic is time-consuming but creates a community of players who know each other. The trust engendered in frequent meetings will smooth the implementation of triage protocols when a pandemic comes.
In summary, the nation has a health care system that is lacking surge capacity. 14 A pandemic will quickly overwhelm hospitals. A multitiered triage system that will help the public focus on home care for the vast majority of the sick will help minimize chaos in the emergency department and reduce the need for severe security measures at the hospital.
Dr. Sanchez is the pandemic preparedness coordinator with the Dallas County Health and Human Services Department. Dr. Adams is the medical director of the Tarrant County Public Health Department.
- Majury A, Ash J, Toye B, et al. Laboratory diagnosis of human infection with avian influenza. Can Med Assoc J . 2006;175(11):1371-1372.
- Glezen WP. Emerging infections: pandemic influenza. Epidemiologic Reviews . 1996;18(1):64-76.
- Lam C, Waldhorn R, Toner E, Inglesby TV, O'Toole T. The prospect of using alternative care facilities in an influenza pandemic. Biosecur Bioterror . 2006;4(4):384-390.
- Inglesby TV, Nuzzo JB, O'Toole T, Henderson DA. Disease mitigation measures in the control of pandemic influenza. Biosecur Bioterror. 2006;4(4):366-375.
- The American Red Cross Pandemic Influenza Preparedness Guide. 2007. http://www.redcross.org/news/ds/panflu/index.html . Accessed July 27, 2007.
- Schull MJ, Stukel TA, Vermeulen MJ, et al. Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome. Can Med Assoc J . 2007;176(13):1827-1832.
- Campbell A. The SARS Commission Interm Report: SARS and Public Health in Ontario: An Executive Summary. Biosecur Bioterror . 2004;2(2):118-126. http://www.libertonline.com/doi/abs/10.1089/153871304323146423 . Accessed June 6, 2007.
- Huang S, Skapinsky K, Sun J, Webb K. The Pandemic Hotline. Social Innovation and Entrepreneurship: Saving Lives in the Next Pandemic. Stanford University; June 7, 2007. http://sie.stanford.edu/1/reports/hotline.pdf. Accessed Aug. 7, 2007.
- Espino JU, Hogan WR, Wagner MM. Telephone triage: a timely data source for surveillance of influenza-like diseases. AMIA Annu Symp Proc . 2003:215-219.
- Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. Can Med Assoc J . 2006;175(11):1377-1381.
- California Department of Health and Human Services. Pandemic Influenza Preparedness and Response Plan. Sept. 8, 2006. Available at: http://www.dhs.ca.gov/ps/dcdc/izgroup/pdf/pandemic.pdf . Accessed July 1, 2007.
- New Jersey Department of Health and Senior Services. Influenza Surge Capacity Guidance for General Hospitals. Nov. 9, 2004. Available at: http://nj.gov/health/flu/documents/flu_scg_110904.pdf . Accessed July 1, 2007.
- Hong Kong Health Welfare and Food Bureau. Framework of Government's Preparedness Plan for Influenza Pandemic. February 2005. Available at: http://www.chp.gov.hk/files/pdf/flu_plan_framework_en_20050222.pdf . Accessed July 1, 2007.
- Preliminary Review of the National EMS Preparedness Initiative Policy Summit, Oct. 16-17, 2006. Washington, D.C.: George Washington University; 2006. http://inside.gwumc.edu/nemspi/documents/nemspi_preliminary_review.pdf . Accessed July 23, 2007.
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