A survey of emergency department 2009 pandemic influenza A (H1N1) surge preparedness--Atlanta, Georgia, July-October 2009

Patient flow management in biological events: a scoping review

INTRODUCTION

Biological Events affect large populations depending on transmission potential and propagation. A recent example of a biological event spreading globally is the COVID-19 pandemic, which has had severe effects on the economy, society, and even politics,in addition to its broad occurrence and fatalities. The aim of this scoping review was to look into patient flow management techniques and approaches used globally in biological incidents.

METHODS

The current investigation was conducted based on PRISMA-ScR: Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. All articles released until March 31, 2023, about research question were examined, regardless of the year of publication. The authors searched in databases including Scopus, Web of Science, PubMed, Google scholar search engine, Grey Literature and did hand searching. Papers with lack of the required information and all non-English language publications including those with only English abstracts were excluded. Data extraction checklist has been developed Based on the consensus of authors.the content of the papers based on data extraction, analyzed using content analysis.

RESULTS

A total of 19,231 articles were retrieved in this study and after screening, 36 articles were eventually entered for final analysis. Eighty-four subcategories were identified,To facilitate more precise analysis and understanding, factors were categorised into seven categories: patient flow simulation models, risk communication management, integrated ICT system establishment, collaborative interdisciplinary and intersectoral approach, systematic patient management, promotion of health information technology models, modification of triage strategies, and optimal resource and capacity management.

CONCLUSION

Patient flow management during biological Events plays a crucial role in maintaining the performance of the healthcare system. When public health-threatening biological incidents occur, due to the high number of patients, it is essential to implement a holistic,and integrated approach from rapid identification to treatment and discharge of patients.

Increase in trauma volume as compared to emergency department volume during the COVID-19 pandemic

BACKGROUND

During the months between April through June 2020 when we experienced the largest number of COVID-19 patients in our hospital, the volume of patients in the Emergency Department (ED) was decreased by more than 30%. In contrast to most early reports we did not notice a decrease in trauma volume during this time period.

MATERIALS AND METHODS

We compared trauma patients presenting to our Level III Trauma Center, between April 2019 through June 2019 to those presenting from April 2020 through June 2020, the initial surge in COVID-19 patients. We compared ground level falls (GLF), motor vehicle crashes (MVC), bicycle and skateboard crashes, assault, and other.

RESULTS

There was a 13% increase in trauma patients presenting during the study period in 2020 as compared to 2019, and the total number of trauma patients as a percentage of total ED patients also increased 269/9235 (2.9%) to 308/6216 (5.0%), P < 0.0001. There was no significant difference in demographics or outcome data between the trauma patients presenting during the two time periods. Although traffic decreased by more than 40%, the number of MVC's was similar.

CONCLUSION

The volume of patients presenting to our Trauma Center as compared to the total ED volume increased during the time period from April through June 2020 versus the year just prior to the COVID-19 pandemic. Despite the fact that the total traffic volume decreased more than 40 percent between these two time periods, the actual number of motor vehicle crashes remained similar.

Pre-COVID-19 Physician Awareness of Mental Health Resources During and After Natural and Human-Made Disasters

OBJECTIVE

Physician mental health is critical during the recovery of natural and human-made disasters (NHDs), yet the accessibility of mental health resources to physicians has not been characterized. This study examined emergency medicine and trauma physician knowledge of and access to mental health resources in NHD settings.

METHODS

The survey was electronically disseminated to the American College of Emergency Physicians and the American Association of the Surgery of Trauma between February 4, 2020, and March 9, 2020. The 17-question survey assessed physician awareness and access to emergency preparedness resources at their institutions.

RESULTS

Of the responders, 86% (n = 229) were aware of written emergency response plans for their facility. While 31% were aware of the hospital's mental health policies and resources outside of the emergency response plan, only 25% knew how to access these resources during and after NHDs. Finally, 10% reported the incorporation of mental health resources during institutional practice drills.

CONCLUSIONS

Physicians reported knowledge of emergency preparedness policies; however, significant gaps remain in physician knowledge and access to mental health resources NHD settings. As NHDs increase on a global scale, it is critical for health systems to ensure accessible infrastructure to support the mental well-being of health professionals.

Pandemics and the Impact on Physician Mental Health: A Systematic Review

Physician mental health is a major area of concern with physician burnout on the rise, while at the same time pandemics are becoming more frequent and serious in nature. This combination of physician burnout and pandemics has the potential for serious negative implications for physicians, patients, and health care organizations. Thus, we conduct a systematic review that examines the effect of pandemics on physician mental health using the burnout cascade as a framework. We identified 30 quantitative studies for inclusion. We find that Stages 4 and 5 of the burnout cascade are particularly troublesome with physicians experiencing high levels of anxiety and depression. Furthermore, we find in the degradation phase that physicians experience stigma which may intensify other negative effects. Physicians who are women, younger, and have less training are more susceptible to the negative effects of pandemics. We discuss overall implications and recommendations for future research.

Accuracy and Acceptance of a Self-Collection Model for Respiratory Tract Infection Diagnostics: A Concise Clinical Literature Review

Background

Nurses are the primary clinicians who collect specimens for respiratory tract infection testing. The specimen collection procedure is time and resource-consuming, but more importantly, it places nurses at risk for potential infection. The practice of allowing patients to self-collect their diagnostic specimens may provide an alternative testing model for the current COVID-19 outbreaks. The objective of this paper was to evaluate the accuracy and patient perception of self-collected specimens for respiratory tract infection diagnostics.

Methods

A concise clinical review of the recently published literature was conducted.

Results

A total of 11 articles were included the review synthesis. The concept of self-collected specimens has a high patient acceptance rate of 83-99%. Self-collected nasal-swab specimens demonstrated strong diagnostic fidelity for respiratory tract infections with a sensitivity between 80-100%, this is higher than the 76% sensitivity observed with self-collected throat specimens. In a comparative study evaluating a professionally collected to a self-collected specimen for COVID-19 testing, a high degree of agreement (k = 0.89) was observed between the two methods.

Conclusion

As we continue to explore for testing models to combat the COVID-19 pandemic, self-collected specimens is a practical alternative to nurse specimen collection.

Operationalizing a Pandemic-Ready, Telemedicine-Enabled Drive-Through and Walk-In Coronavirus Disease Garage Care System as an Alternative Care Area: A Novel Approach in Pandemic Management

OBJECTIVE

Emergency departments face unforeseen surges in patients classified as low acuity during pandemics such as the coronavirus disease pandemic. Streamlining patient flow using telemedicine in an alternative care area can reduce crowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment use. This quality improvement project describes critical elements and processes in the operationalization of a telemedicine-enabled drive-through and walk-in garage care system to improve ED throughput and conserve personal protective equipment during 3 coronavirus disease surges in 2020.

METHODS

Standardized workflows were established for the operationalization of the telemedicine-enabled drive-through and walk-in garage care system for patients presenting with respiratory illness as quality improvement during disaster. Statistical control charts present interrupted time series data on the ED length of stay and personal protective equipment use in the week before and after deployment in March, July, and November 2020.

RESULTS

Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the telemedicine-enabled drive-through and walk-in garage care system. On average, the ED length of stay decreased 17%, from 4.24 hours during the week before opening to 3.54 hours during the telemedicine-enabled drive-through and walk-in garage care system operation. There was an estimated 25% to 41% reduction in personal protective equipment use during this time.

CONCLUSION

Lessons learned from this telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce crowding, improve throughput, and conserve personal protective equipment during a pandemic.

Impact of a Novel Emergency Department Forward Treatment Area During the New York City COVID-19 Surge

INTRODUCTION

Coronavirus disease 2019 (COVID-19) caused a disproportionate number of patients to seek emergency care at hospitals in New York City (NYC) during the initial crisis. Our urban emergency department (ED), a member of the NYC public hospital system had to process the increased volume while also differentiating our patients' critical needs. We established a forward treatment area (FTA) directly in front of the ED to accomplish these goals from March 23-April 16, 2020.

METHODS

A clinical greeter evaluated patients 18 years and older who presented to the walk-in entrance of the ED where they were screened for COVID-19-like complaints. If they did not appear critically ill and could ambulate they were directed into the FTA. Clinical and non-clinical staff worked in concert to register, evaluate, and process patients with either a disposition of directly home or into the ED for further care.

RESULTS

A total of 634 patients were seen in the FTA from March 23-April 16, 2020. Of the 634 patients evaluated, 135 (21%) were referred into the ED for further evaluation, of whom 81 (12.7% of the total) were admitted. These patients were disproportionately male (91 into the ED and 63 admitted) and tended to have a higher heart rate (105.4 vs 93.7), a higher respiratory rate (21.5 vs 18.1), and lower oxygen saturation (93.9% vs 97.8%).

CONCLUSION

A forward treatment area is an effective method to rapidly screen and process an increased volume of COVID-19 patients when resources are limited. This treatment area helped decompress the ED by being rapidly deployable and effectively screening patients for safe discharge home.

Worsening of emergency department length of stay during the COVID-19 pandemic

OBJECTIVE

Our study sought to determine whether there was a change in emergency department (ED) length of stay (LOS) during the coronavirus disease 2019 (COVID-19) pandemic compared to prior years.

METHODS

We performed a retrospective analysis using ED performance data 2018-2020 from 56 EDs across the United States. We used a generalized estimating equation (GEE) model to assess differences in ED LOS for admitted (LOS-A) and discharged (LOS-D) patients during the COVID-19 pandemic period compared to prior years.

RESULTS

GEE modeling showed that LOS-A and LOS-D were significantly higher during the COVID-19 period compared to the pre-COVID-19 period. LOS-A during the COVID-19 period was 10.3% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 28 minutes. LOS-D during the COVID-19 period was 2.8% higher compared to the pre-COVID-19 time period, which represents a higher geometric mean of 2 minutes.

CONCLUSIONS

ED LOS-A and LOS-D were significantly higher in the COVID-19 period compared to the pre-COVID-19 period despite a lower volume of patients in the COVID-19 period.

Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic precipitated fear of contagion and influenced many people to avoid the emergency department (ED). It is unknown if this avoidance effected overall health or disease mortality.

OBJECTIVE

We aimed to quantify the decreased ED volume in the United States, determine whether it occurred simultaneously across the country, find which types of patients decreased, and measure resultant changes in patient outcomes.

METHODS

We retrospectively accessed a multihospital, multistate electronic health records database managed by HCA Healthcare to obtain a case series of all patients presenting to an ED during the early COVID-19 pandemic (March 1-May 31, 2020) and the same dates in 2019 for comparison. We determined ED volume using weekly totals and grouped them by state. We also recorded final diagnoses codes and mortality data to describe patient types and outcomes.

RESULTS

The weekly ED volume from 160 facilities dropped 44% from 141,408 patients (week 1, March 1-7, 2020) to a nadir of 79,618 patients (week 7, April 12-18, 2020), before rising back to 105,667 (week 13, May 24-30, 2020). Compared with 2019, this overall decline was statistically significant (p < 0.001). The decline was universal across disease categories except for infectious disease and respiratory illnesses, which increased. All-cause mortality increased during the pandemic, especially for those with infectious disease, circulatory, and respiratory illnesses.

CONCLUSIONS

The COVID-19 pandemic and an apparent fear of contagion caused a decrease in ED presentations across our hospital system. The decline in ED volume was associated with increased ED mortality, perhaps from delayed ED presentations.

Novel Use of Rapid Antigen Influenza Testing in the Outpatient Setting To Provide an Early Warning Sign of Influenza Activity in the Emergency Departments of an Integrated Health System

Seasonal influenza virus is associated with high morbidity and mortality especially in vulnerable patient populations. Here, we demonstrate the novel use of Sofia influenza A+B fluorescent immunoassay (FIA), a rapid antigen-based influenza point-of-care test (POCT), combined with Virena software for automatic deidentified tracking of influenza activity across the Los Angeles area and for predicting surges of influenza cases in the emergency department (ED). We divided outpatient clinics into 6 geographic zones and compared weekly influenza activity. In the outpatient setting, there were 1,666 and 274 influenza A and influenza B positives, respectively, across the 2018 to 2019 influenza season and 1,857 and 1,449 influenza A and influenza B positives, respectively, during the 2019 to 2020 influenza season, with zone-specific differences observed. Moreover, we found that a rapid increase in outpatient influenza was followed by an influx in influenza-positive cases in the ED, offering a 1- to 3-week warning sign for ED influx of triple or quadruple the number of influenza cases compared to the prior week. Sofia influenza A+B FIA allows for surveillance of real-time deidentified influenza activity. Tracking of such data may serve as a valuable region-specific influenza indicator and predictor to guide infection prevention measures in both the outpatient and hospital settings. High-impact interventions include designating areas for waiting rooms for influenza-like illnesses, altering staff scheduling in anticipation of surges, and securing sufficient personal protective equipment and antivirals during the height of influenza season.

Anatomy of a demand shock: Quantitative analysis of crowding in hospital emergency departments in Victoria, Australia during the 2009 influenza pandemic

Objective

An infectious disease outbreak such as the 2009 influenza pandemic is an unexpected demand shock to hospital emergency departments (EDs). We analysed changes in key performance metrics in (EDs) in Victoria during this pandemic to assess the impact of this demand shock.

Design and setting

Descriptive time-series analysis and longitudinal regression analysis of data from the Victorian Emergency Minimum Dataset (VEMD) using data from the 38 EDs that submit data to the state’s Department of Health and Human Services.

Main outcome measures

Daily number of presentations, influenza-like-illness (ILI) presentations, daily mean waiting time (time to first being seen by a doctor), daily number of patients who did-not-wait and daily number of access-blocked patients (admitted patients with length of stay >8 hours) at a system and hospital-level.

Results

During the influenza pandemic, mean waiting time increased by up to 25%, access block increased by 32% and did not wait presentations increased by 69% above pre-pandemic levels. The peaks of all three crowding variables corresponded approximately to the peak in admitted ILI presentations. Longitudinal fixed-effects regression analysis estimated positive and statistically significant associations between mean waiting times, did not wait presentations and access block and ILI presentations.

Conclusions

This pandemic event caused excess demand leading to increased waiting times, did-not-wait patients and access block. Increases in admitted patients were more strongly associated with crowding than non-admitted patients during the pandemic period, so policies to divert or mitigate low-complexity non-admitted patients are unlikely to be effective in reducing ED crowding.

Health system capacity in Sydney, Australia in the event of a biological attack with smallpox

Planning for a re-emergent epidemic of smallpox requires surge capacity of space, resources and personnel within health systems. There are many uncertainties in such a scenario, including likelihood and size of an attack, speed of response and health system capacity. We used a model for smallpox transmission to determine requirements for hospital beds, contact tracing and health workers (HCWs) in Sydney, Australia, during a modelled epidemic of smallpox. Sensitivity analysis was done on attack size, speed of response and proportion of case isolation and contact tracing. We estimated 100638 clinical HCWs and 14595 public hospital beds in Sydney. Rapid response, case isolation and contact tracing are influential on epidemic size, with case isolation more influential than contact tracing. With 95% of cases isolated, outbreak control can be achieved within 100 days even with only 50% of contacts traced. However, if case isolation and contact tracing both fall to 50%, epidemic control is lost. With a smaller initial attack and a response commencing 20 days after the attack, health system impacts are modest. The requirement for hospital beds will vary from up to 4% to 100% of all available beds in best and worst case scenarios. If the response is delayed, or if the attack infects 10000 people, all available beds will be exceeded within 40 days, with corresponding surge requirements for clinical health care workers (HCWs). We estimated there are 330 public health workers in Sydney with up to 940,350 contacts to be traced. At least 3 million respirators will be needed for the first 100 days. To ensure adequate health system capacity, rapid response, high rates of case isolation, excellent contact tracing and vaccination, and protection of HCWs should be a priority. Surge capacity must be planned. Failures in any of these could cause health system failure, with inadequate beds, quarantine spaces, personnel, PPE and inability to manage other acute health conditions.

Seasonal dengue surge: Providers⬨tm) perceptions about the impact of dengue on patient volume, staffing and use of point of care testing in Indian emergency departments

BACKGROUND

Global health emergencies, such as from diseases like dengue fever, can lead to rapid surges in visits to emergency departments. The objective of our study was to evaluate the impact of dengue on factors that could impact emergency department flow, including patient volume and staffing, on Indian emergency departments.

METHODS

This was a prospective cohort study of Indian emergency providers. Respondents were queried via online survey about a number of domains including practice environment, use of rapid testing, changes in ED volume and ED staffing adjustments occurring during dengue season. Data was analyzed using multivariate analysis.

RESULTS

We had a total of 210 respondents to our online survey. Less than half of respondents reported that their institutions used rapid point of care testing. When asked how dengue impacted ED flow, the most common response was that dengue increased the total number of ED visits (84%). Despite this increase, only about 32% of respondents reported that their institutions increased hospital staffing. In multivariate analysis, respondents at hospitals that experienced ED visit surges over 40% of baseline were more likely to also report that their institutions also increased staffing during this time (OR 3.28, 95% CI 1.44-7.46).

CONCLUSIONS

Our study shows that despite increases in visits during dengue season, ED providers noted that their EDs did not respond with staffing increases. More research is needed to better understand how emergency departments can adjust to dengue to provide optimal care for patients in India.

Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department

To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.

The Impact of a Case of Ebola Virus Disease on Emergency Department Visits in Metropolitan Dallas-Fort Worth, TX, July, 2013-July, 2015: An Interrupted Time Series Analysis

Background:

The first Ebola virus disease (EVD) case in the United States (US) was confirmed September 30, 2014 in a man 45 years old. This event created considerable media attention and there was fear of an EVD outbreak in the US.

Methods:

This study examined whether emergency department (ED) visits changed in metropolitan Dallas-Fort Worth­­, Texas (DFW) after this EVD case was confirmed. Using Texas Health Services Region 2/3 syndromic surveillance data and focusing on DFW, interrupted time series analyses were conducted using segmented regression models with autoregressive errors for overall ED visits and rates of several chief complaints, including fever with gastrointestinal distress (FGI). Date of fatal case confirmation was the “event.”

Results:

Results indicated the event was highly significant for ED visits overall (P<0.05) and for the rate of FGI visits (P<0.0001). An immediate increase in total ED visits of 1,023 visits per day (95% CI: 797.0, 1,252.8) was observed, equivalent to 11.8% (95% CI: 9.2%, 14.4%) increase ED visits overall. Visits and the rate of FGI visits in DFW increased significantly immediately after confirmation of the EVD case and remained elevated for several months even adjusting for seasonality both within symptom specific chief complaints as well as overall.

Conclusions:

These results have implications for ED surge capacity as well as for public health messaging in the wake of a public health emergency.

The Impact of Middle East Respiratory Syndrome Outbreak on Trends in Emergency Department Utilization Patterns

Changes occurred in the patterns of utilization of emergency medical services during the Middle East respiratory syndrome (MERS) outbreak. The purpose of this study was to analyze the patterns of adult and pediatric patients who visited the emergency department (ED) during the outbreak. This retrospective study was conducted by analyzing changes in the patterns of visits among adult and pediatric patients in the ED at one tertiary teaching hospital in Korea. The study was performed from June 1, 2013 to July 31, 2015. The MERS outbreak period was from June 1 to July 31, 2015, and we compared that period to the same periods in 2013 and 2014. We compared and analyzed the patients' characteristics, emergency severity index (ESI) level at the visit, cause of visit, diagnosis, final dispositions, injury/non-injury, length of stay at the ED (EDLOS), and hospitalization rate. A total of 9,107 patients visited the ED during this period. Of these patients, 2,572 (28.2%) were pediatric patients and 6,535 (71.8%) were adult patients. The most common cause of an ED visit was fever (adult patients: 21.6%, pediatric patients: 56.2%). The proportion of non-urgent visits involving an ESI level of 4 or 5 and the EDLOS decreased significantly in pediatric and adult patients in comparison to that during the past two years. This change was significant in pediatric patients. Among adult patients, the rate of injury decreased, whereas it increased among pediatric patients. During the MERS outbreak period, pediatric ED visits due to non-urgent cases decreased significantly and there were more pronounced differences in ED utilization patterns in pediatric patients than in adult patients.

Bridging the gap between guidelines and practice in the management of emerging infectious diseases: a qualitative study of emergency nurses

AIMS AND OBJECTIVES

To explore the difficulties and strategies regarding guideline implementation among emergency nurses.

BACKGROUND

Emerging infectious diseases remain an underlying source of global health concern. Guidelines for accident and emergency departments would require adjustments for infectious disease management. However, disparities between guidelines and nurses' practice are frequently reported, which undermines the implementation of these guidelines into practice. This article explores the experience of frontline emergency nurses regarding guideline implementation and provides an in-depth account of their strategies in bridging guideline-practice gaps.

DESIGN

A qualitative descriptive design was used.

METHODS

Semi-structured, face-to-face, individual interviews were conducted between November 2013-May 2014. A purposive sample of 12 frontline emergency nurses from five accident and emergency departments in Hong Kong were recruited. The audio-recorded interviews were transcribed verbatim and analysed with a qualitative content analysis approach.

RESULTS

Four key categories associated with guideline-practice gaps emerged, including getting work done, adapting to accelerated infection control measures, compromising care standards and resolving competing clinical judgments across collaborating departments. The results illustrate that the guideline-practice gaps could be associated with inadequate provision of corresponding organisational supports after guidelines are established.

CONCLUSIONS

The nurses' experiences have uncovered the difficulties in the implementation of guidelines in emergency care settings and the corresponding strategies used to address these problems. The nurses' experiences reflect their endeavour in adjusting accordingly and adapting themselves to their circumstances in the face of unfeasible guidelines.

RELEVANCE TO CLINICAL PRACTICE

It is important to customise guidelines to the needs of frontline nurses. Maintaining cross-departmental consensus on guideline interpretation and operation is also indicated as an important component for effective guideline implementation.

Physician Emergency Preparedness: A National Poll of Physicians

OBJECTIVE

To provide a more comprehensive view than previously available of US physician preparedness for public health emergencies, this study examined physicians' assessments of their preparedness, training, participation in institutional activities, information practices, and experiences with patient education. Four kinds of public health emergencies were considered: natural disasters, major airborne infections, major foodborne illness outbreaks, and chemical, biological, radiological, nuclear, or explosives (CBRNE) incidents.

METHODS

Between October 19, 2011, and January 11, 2012, researchers conducted a national poll among 1603 practicing physicians in a range of specialties in hospital and nonhospital settings.

RESULTS

More than one-half of physicians felt prepared to handle a natural disaster, a major outbreak of an airborne infection, or a major foodborne illness outbreak, whereas one-third (34%) felt prepared to handle a CBRNE incident. About one-half of physicians (55%) had participated in training or a conference related to emergencies in the past 2 years. Sizable fractions of physicians were unaware of emergency response tools in their care setting. For example, nearly one-half in hospitals (44%) did not know whether their care setting had an emergency response plan, and less than one-quarter had participated in a drill using such a plan in the past 2 years. Less than one-third (31%) of physicians had signed up to receive alerts in the case of future emergencies. One in 10 reported sharing emergency information with patients at least "sometimes."

CONCLUSIONS

Significant gaps remain in physician preparedness for public health emergencies, as well as in related training and participation in institutional activities. New efforts, with a focus on possible collaborations between public health institutions and health system leaders combined with effective use of online resources, are needed to bring more physicians on board and to develop relevant and useful key tools. New approaches, including those that rely on different types of care providers, may be needed to enhance patient education regarding emergency preparedness.

Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel.

RESULTS

This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure).

CONCLUSIONS

Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.

Perceptions of emergency nurses during the human swine influenza outbreak: a qualitative study

INTRODUCTION

The primary aim of this study was to explore the perception of Hong Kong emergency nurses regarding their work during the human swine influenza pandemic outbreak.

METHODS

In this exploratory, qualitative study, 10 emergency nurses from a regional hospital in Hong Kong were recruited using purposive sampling. Semi-structured, face-to-face individual interviews were conducted. Qualitative content analysis was utilized to analyze the transcripts.

RESULTS

The three following categories emerged from the interview data: concerns about health, comments on the administration, and attitudes of professionalism. Nurses viewed the human swine influenza as a threat to their personal and families' health. However, nurses perceived that the severity of the disease was exaggerated by the public. Improvements in planning the circulation of information, allocation of manpower, and utilization of personal protective equipment were indicated. The emergency nurses demonstrated a sense of commitment and professional morale in promoting a high quality of nursing care.

DISCUSSION

Various factors affecting the perceptions of emergency nurses toward their professional duties during the influenza pandemic were identified. By understanding these perceptions, appropriate planning, policies, and guidelines can be formulated to meet the healthcare needs of patients during future pandemic outbreaks.

Interventions to mitigate emergency department and hospital crowding during an infectious respiratory disease outbreak: results from an expert panel

OBJECTIVE

To identify and prioritize potential Emergency Department (ED) and hospital-based interventions which could mitigate the impact of crowding during patient surge from a widespread infectious respiratory disease outbreak and determine potential data sources that may be useful for triggering decisions to implement these high priority interventions.

DESIGN

Expert panel utilizing Nominal Group Technique to identify and prioritize interventions, and in addition, determine appropriate "triggers" for implementation of the high priority interventions in the context of four different infectious respiratory disease scenarios that vary by patient volumes (high versus low) and illness severity (high versus low).

SETTING

One day in-person conference held November, 2011.

PARTICIPANTS

Regional and national experts representing the fields of public health, disease surveillance, clinical medicine, ED operations, and hospital operations.

MAIN OUTCOME MEASURE

Prioritized list of potential interventions to reduce ED and hospital crowding, respectively. In addition, we created a prioritized list of potential data sources which could be useful to trigger interventions.

RESULTS

High priority interventions to mitigate ED surge included standardizing admission and discharge criteria and instituting infection control measures. To mitigate hospital crowding, panelists prioritized mandatory vaccination and an algorithm for antiviral use. Data sources identified for triggering implementation of these interventions were most commonly ED and hospital utilization metrics.

CONCLUSIONS

We developed a prioritized list of potentially useful interventions to mitigate ED and hospital crowding in various outbreak scenarios. The data sources identified to "trigger" the implementation of these high priority interventions consist mainly of sources available at the local, institutional level.

Pandemic planning and response in academic pediatric emergency departments during the 2009 H1N1 influenza pandemic

OBJECTIVES

The terrorist attacks of September 11, 2001, initiated a shift toward a comprehensive, or "all-hazards," framework of emergency preparedness in the United States. Since then, the threat of H5N1 avian influenza, the severe acute respiratory syndrome epidemic, and the 2009 H1N1 influenza pandemic have underscored the importance of considering infectious events within such a framework. Pediatric emergency departments (EDs) were disproportionately burdened by the 2009 H1N1 influenza pandemic and therefore serve as a robust context for evaluation of pandemic preparedness. The objective of this study was to explore pediatric ED leaders' experiences with preparedness, response, and postincident actions related to the H1N1 pandemic to inform future pandemic and all-hazards planning and policy for EDs.

METHODS

The authors selected a qualitative design, well suited for exploring complex, multifaceted organizational processes such as planning for and responding to a pandemic and learning from institutional experiences. Purposeful sampling was used to recruit medical directors or their designated physician respondents from pediatric emergency medicine training institutions representing a range of geographic regions across the United States, hospital types, and annual ED volumes; snowball sampling identified additional information-rich respondents. Recruitment began in May 2011 and continued until thematic saturation was reached in January 2012 (n = 20). Data were collected through in-depth individual phone interviews that were recorded and professionally transcribed. Using a standard interview guide, respondents were asked open-ended questions about pandemic planning, response, and institutional learning related to the H1N1 pandemic. Data analysis was performed by a multidisciplinary team using a grounded theory approach to generate themes inductively from respondents' expressed perspectives. The constant comparative method was used to identify emerging themes.

RESULTS

Five common themes characterized respondents' experiences with pandemic planning and response: 1) national pandemic influenza preparedness guidance has not fully penetrated to the level of pediatric emergency physician (EP) leaders, leading to variable states of preparedness; 2) pediatric EDs that maintained strong relationships with local public health and other health care entities found those relationships to be beneficial to pandemic response; 3) pediatric EP leaders reported difficulty reconciling public health guidance with the reality of ED practice; 4) although many anticipated obstacles did not materialize, in some cases pediatric EP leaders experienced unexpected institutional challenges; and 5) pediatric EP leaders described varied experiences with organizational learning following the H1N1 pandemic experience.

CONCLUSIONS

Despite a decade of investment in hospital preparedness, gaps in pediatric ED pandemic preparedness remain. This work suggests that raising awareness of pandemic planning standards and promoting strategies to overcome barriers to their adoption could enhance ED and hospital preparedness. Helping hospitals better prepare for pandemic events may lead to strengthened all-hazards preparedness.

Infection control management of patients with suspected highly infectious diseases in emergency departments: data from a survey in 41 facilities in 14 European countries

BACKGROUND

In Emergency and Medical Admission Departments (EDs and MADs), prompt recognition and appropriate infection control management of patients with Highly Infectious Diseases (HIDs, e.g. Viral Hemorrhagic Fevers and SARS) are fundamental for avoiding nosocomial outbreaks.

METHODS

The EuroNHID (European Network for Highly Infectious Diseases) project collected data from 41 EDs and MADs in 14 European countries, located in the same facility as a national/regional referral centre for HIDs, using specifically developed checklists, during on-site visits from February to November 2009.

RESULTS

Isolation rooms were available in 34 facilities (82,9%): these rooms had anteroom in 19, dedicated entrance in 15, negative pressure in 17, and HEPA filtration of exhausting air in 12. Only 6 centres (14,6%) had isolation rooms with all characteristics. Personnel trained for the recognition of HIDs was available in 24 facilities; management protocols for HIDs were available in 35.

CONCLUSIONS

Preparedness level for the safe and appropriate management of HIDs is partially adequate in the surveyed EDs and MADs.

Google Flu Trends: correlation with emergency department influenza rates and crowding metrics

BACKGROUND

 Google Flu Trends (GFT) is a novel Internet-based influenza surveillance system that uses search engine query data to estimate influenza activity and is available in near real time. This study assesses the temporal correlation of city GFT data to cases of influenza and standard crowding indices from an inner-city emergency department (ED).

METHODS

 This study was performed during a 21-month period (from January 2009 through October 2010) at an urban academic hospital with physically and administratively separate adult and pediatric EDs. We collected weekly data from GFT for Baltimore, Maryland; ED Centers for Disease Control and Prevention-reported standardized influenzalike illness (ILI) data; laboratory-confirmed influenza data; and ED crowding indices (patient volume, number of patients who left without being seen, waiting room time, and length of stay for admitted and discharged patients). Pediatric and adult data were analyzed separately using cross-correlation with GFT.

RESULTS

 GFT correlated with both number of positive influenza test results (adult ED, r = 0.876; pediatric ED, r = 0.718) and number of ED patients presenting with ILI (adult ED, r = 0.885; pediatric ED, r = 0.652). Pediatric but not adult crowding measures, such as total ED volume (r = 0.649) and leaving without being seen (r = 0.641), also had good correlation with GFT. Adult crowding measures for low-acuity patients, such as waiting room time (r = 0.421) and length of stay for discharged patients (r = 0.548), had moderate correlation with GFT.

CONCLUSIONS

 City-level GFT shows strong correlation with influenza cases and ED ILI visits, validating its use as an ED surveillance tool. GFT correlated with several pediatric ED crowding measures and those for low-acuity adult patients.