Pandemic Influenza Triage in the Clinical Setting

1
Pandemic Influenza Triage in the Clinical Setting

• Steven J. Rottman, Kimberley I. Shoaf,
• Jennifer Schlesinger, Eva Klein Selski,
• Joey Perman, Kerry Lamb, and Janet Cheng

2
Are Clinical Practitioners Thinking About Pan Flu?

• Since hospital emergency departments will be a
  point of impact for those seeking care
• Are staff aware of the potential for pandemic?
• What are the implications in the emergency
  setting?
• Is there guidance for the clinical management of
  large numbers of variably ill patients?

3
Background Types of Influenza

• Seasonal flu
• Avian flu
• Pandemic flu

4
H5N1 Avian Influenza

• 2007
• Human-to-human transmission
• Bird Outbreaks
• 2008
• 373 Human cases
• 63 Case Fatality
• 14 Countries affected

5
20th Century Pandemics
6
Pandemic Influenza Today?

• In the United States
• 1.9 million people could die
• 9.9 million could be hospitalized
• 90 million could become ill
• Intense pressure on healthcare
• Disruption to many aspects of daily life

7
Federal Recognition
8
Steps Taken Since 2000

• August 26, 2004 HHS Issues National Pandemic
  Influenza Preparedness Plan
• November 2005 National Strategy to Safeguard
  Against Pandemic Influenza
• 2006-2007 400 million to all States for Pan Flu
  Planning
• March 2006 Hospital Pandemic Influenza
  Guidelines for Acute Care Hospital Settings LA
  County Dept Public Health
• September 12, 2007 Hospital Pandemic Influenza
  Planning Checklist HHS

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Methods

• Key Informant Interviews
• IRB approval and participant consent forms
• Recorded
• Transcribed
• Coded for themes

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Open-Ended Prompts

• Four general themes
• Supplies/Resources of the institution
• Triage parameters within the institution
• Quality of Care
• Authority for Institutional Decisions

11
The Sample

• Convenience Sample
• ED Nurse (7)
• ED Physician (11)
• Infection control (9)
• Nursing Supervisor (9)
• Hospital Administrator (10)

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FindingsStatus Quo

• Its just another bad day
• I dont really feel we would do anything
  different for any kind of disaster, either flu or
  bioterrorism. (Inf. Control)
• Whether our patients are urgent or non-urgent,
  they all get the same type of care. (ED MD)
• I dont know what lower quality of care would
  mean. I dont think it will be my concern. (RN
  Sup)

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Recognition of the Problem

• The biggest concern is the emotional wear and
  tear on the staffwe think we can do the best for
  everybody. Sometimes we just cant. (ED RN)
• you cant save everybody. You are going to
  have to use your resources for those that can be
  saved. (RN Sup)
• I dont think we have that kind of experience I
  dont think we have the training to understand
  what decisions might need to be made. (ED MD)

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Quality of Care

• Stratification of the quality of care
• Decreased staffing/resources recognized but not
  connected to reduced standards of medical care
• Ethical Concerns

15
Triage

• Logistical Concerns
• Triage Site
• Lack of Staff
• Infection Control
• Patient Surge
• Chaos/crowd control

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Institutional Needs

• Logistical and Macro-level
• Staffing
• Resources
• Training
• Operational Guidelines
• Triage, MD Licensing, Liability

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The Public

• Need for public education
• Symptoms
• Social Distancing
• Public reactions/behavior
• Worried well
• Vulnerable populations

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Need for Public Health Action

• I think we need that expert voice in Public
  Health. We dont need it at the time we need
  it now. (RN Sup)
• There needs to be some coordinated effort,
  increased awareness, and some guidance for
  preparedness. (Adm)
• The Dept of Health is some mysterious agency
  that Ive never seen. Ive never heard from
  them. We dont know who they are. (ED MD)

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Conclusion

• Qualitative assessment
• Los Angeles specific
• Different kinds of institutions and staff roles
  provided a glimpse of common themes
• Preparation and planning must continue

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Inspirational Quotes
Is there really going to be a pandemic flu? Is
it going to be in our life time? (RN Sup)At
least from what Ive been able to read, its
possible we could be overwhelmed. (Adm) God
help us all if it really happens. (Adm)
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References

• PandemicFlu.gov
• US Dept of Health Human Services. HHS Pandemic
  Influenza Plan. http//www.hhs.gov/pandemicflu/pla
  n/part1.html
• Center for Disease Control PreventionInterim
  Pre-Pandemic Planning Guidance Community
  Strategy for Pandemic Influenza Migration in the
  United States
• Southern California Summit on Cross-Sector
  Pandemic Influenza Planning. California
  Department of Public Health.
• Bartlett, JG. Planning for Avian Influenza.
  Annals of Internal Medicine. 2006 145. p.141-144

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• Thank you!
• Joey Perman
• jperman_at_ucla.edu