Have you ever participated in a school fire drill? If you have, you've been part of a live disaster exercise. And like fire drills, the health system (including hospitals and public health) need to run their own drills to see what works and what needs to be done better so as to be better able to handle a natural disaster like the California wildfires or a pandemic. We ran an interesting drill last weekend to practice how my local area would respond to an influenza pandemic.
Part of the the health reform task is to make sure that natural disasters such as hurricanes, wildfires and (yes) influenza pandemics can be approached and mitigated by improving medical and public health infrastructure. One way to do this is to examine and improve the ability of hospitals to care for an excess number of patients for at least short periods of time. However, this can lead to concern about playing the fear card, and overdoing response. Despite those concerns, there's need to plan for surge.
California has led the way, with careful definitions:
A healthcare surge is proclaimed in a local jurisdiction when an authorized local official, such as a local health officer or other appropriate designee,3 using professional judgment determines, subsequent to a significant emergency or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources and/or emergency medical services. The local health official uses the situation assessment information provided from the healthcare delivery system partners to determine overall local jurisdiction/Operational Area medical and health status.
Healthcare surge is not the frequent emergency department overcrowding experienced by healthcare facilities (for example, Friday/Saturday night emergencies). It is also not a local casualty emergency that might overcrowd nearby facilities but have little to no impact on the overall healthcare delivery system.
As defined above, a healthcare surge will directly impact a provider's ability to acquire and manage resources under their normal procedures.
This means that during times of stress to the system, usual standards of care will need to be switched to what's called 'essential care', the provision of which will mean different standards than what the public is used to.
An influenza pandemic is an example of the type of natural disaster that would require health care surge. As an update of where we are at with H5N1 and bird flu, try this piece from the Times (UK):
It is now five years since the present outbreak of H5N1 avian flu first infected people. Though 379 people have since contracted the virus, of whom 239 have died, it has yet to start a pandemic.
As its name suggests, bird flu remains predominantly an avian disease. While it is very dangerous to humans who catch it, this has happened only rarely, after close contact with infected birds.
This week, however, brought some alarming news. Writing in The Lancet, a Chinese medical team confirmed that a 52-year-old man who contracted H5N1 in Jiangsu province last December almost certainly caught it from his 24-year-old son, who died. It is the best-documented case of human-to-human transmission to date.
That is important because, if this virus is going to start a pandemic, it must first acquire the ability to move readily from person to person. Not enough people are ever going to catch it from birds to constitute a global threat. The Chinese case, like a previous suspected human-to-human incident in Thailand, has thus raised fears that H5N1 might be mutating in worrying fashion, and it was duly reported around the world.
The details of the Lancet study, however, are less troubling than they at first appear. This investigation of this cluster of infections, indeed, is somewhat reassuring because of what it shows has not happened.
It has not become easier to catch, and human-to-human (H2H) transmission remains rare - but not unknown. Similar H2H spread was also documented in Pakistan last year, in a case that involved a family member traveling to the United States. But whether the next pandemic is H5N1 or some other virus, pandemics are inevitable. Since it's not a matter of "if", but "when", planning has to occur to cover the areas where we will be short. In other words, since 20-30% of the public will be ill, pandemics will cause the health system to run short of staff, space and stuff... the exact things that surge tries to alleviate.
There's only one problem... no matter how hard you try, you'll still run short. And for that reason, even creative solutions will need to be coupled with unpleasantry in the form of rationing. Whether it's rationing of space or of resources, triage of pateints will be an inevitable consequence of too many ill and not enough resources.
More on the flip...
This triage discussion has already begun. New York State, for example, has developed ventilator triage in the event of a pandemic:
Ventilators may be in short supply in a flu pandemic, so New York state officials have drafted guidelines to determine which patients would get one if there weren't enough to go around.
Similar suggestions have been made for ICU beds.
Development of a triage protocol for critical care during an influenza pandemic
California takes it one step further:
The new "surge capacity guidelines" - which authorities hope will serve as guidlines for hospitals nationwide, especially in the event of a pandemic - calls for letting older, sicker patients be allowed to die in order to save the lives of patients more likely to survive a catastrophic public health crisis.
"During a major disaster, the heath care system will look very different from what we are accustomed to," said Dr. Mark Horton, director of the California Department of Public Health. "These guidelines will help communities as they plan how to sustain a functioning health care system following a catastrophic event such as a severe earthquake, bioterrorism attack or outbreak of pandemic influenza."
So, with that grim background in mind, 40 local businesses and organizations where I live and work decided to explore a different method of surge.
In the event of a pandemic, the hospital would be overflowing with patients. To alleviate some of the bed crunch, the area nursing homes and extended care facilities would pool their available beds, accept transfers from the hospital to free up bed space, and utilize empty beds remaining to act as a 23 hour alternate care facility for flu patients. The Ottilie W. Lundgren Memorial Field Hospital would be set up adjacent to an area nursing home (not the hospital), and the parking garage would be used as a drive-thru (stay in your car) flu clinic...
For more details on the drill, see the news reports and the video:
The concept here is that if local nursing homes and rehab centers join the hospitals and the public health departments (a public-private consortium), and get volunteers from the nursing schools and EMT classes, communities can work together to mitigate disaster. That doesn't make disasters go away (you can't stop a hurricane or a pandemic), but at least you can work on rational response to increase that which you are short, and try to minimize the amount of rationing that will have to be done.
To minimize is not to eliminate. Tough choices would still be made, and home care in one form or another would still be needed. To that end, personal preparation never stops being needed. More people would need to be cared for at home than in the hospitals, and without decent home care, planned in advance, and including food and water so as to be able to stay at home with ill family members (HHS recommends two weeks of food and water be stockpiled by all Americans), increased surge capacity will not be enough.
Through websites like www.getpandemicready.org and Flu Wiki (both of which I have contributed material to), and though service organizations like American Red Cross and Lions Clubs, and professional organizations like Trust for America's Health and the American Academy of Pediatrics, serious steps are being taken to prepare.
Now, a brief word about drills and exercises. The outcomes are: we did it well, or we could do it better. They always succeed. That's because even when things don't go as planned (and they never do), there's something valuable to be learned.
The drill we undertook was therefore successful (it was the first panflu live exercise ever done in the state), but there were valuable lessons to learn. One is that just-in-time training has to be intense. Another is that a single drive-thru clinic in a severe pandemic will not be enough. And yet another is that the response has to be community-wide, and include the public (our volunteers numbered in the hundreds), to make it work.
There's more work to be done... the results need to be reviewed, and improvements implemented, and the new plan trained to, and drilled again. But in planning and practicing surge, the community is strengthened for whatever disaster comes, and thereby helped. This is a practical example of how planning for pandemics can bring communities together, help rebuild infrastructure, and thereby contribute to health reform.
For more blogging on pandemic exercises, see The Pandemic Flu Drive-Thru Clinic Exercise and Pandemic Flu Exercise part II. For state pandemic exercises, see Efforts To Improve in Connecticut. For CDC drills, see Flu Stories: CDC Practices and Plans For An Influenza Pandemic While Hong Kong Executes and for HHS drills, see What's The Role The Internet Will (And Should) Play During A Pandemic?. The question is not why these people are exercising. The question is why aren't you?