In addition to the threat of high morbidity

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1 HEALTH SEVICES Hospital capacity and management pepaedness fo pandemic influenza in Victoia Ben Dewa, 1 Ian Ba, 2 Piscilla obinson 1 In addition to the theat of high mobidity and motality, influenza pandemics can ovewhelm health systems and cause significant societal and economic disuption. 1 Pandemic pepaedness planning is vital fo ensuing health and othe essential systems continue functioning duing a pandemic, theeby educing the economic and social cost. 2 Austalia s Chief edical Office stated that although Austalia s health system was stessed duing the 2009 pandemic, spae capacity in hospital beds was available. 3 Also, due to the low ates of admission, ICUs wee still able to cope with the inceased demand and esouce use such as ECO (extacopoeal membane oxygenation) of H1N1 patients 4 even duing the peak in July In shot, even though the 2009 H1N1 pandemic may have ovewhelmed the Austalian health system, it did not mainly due to the geneally mild natue of the vius. Howeve, thee is no guaantee that a futue pandemic will not be moe sevee and may indeed swamp the system. One of the lessons highlighted by the 2009 H1N1 influenza pandemic was the need fo health sevices, especially those with citical cae facilities such as ICUs and Emegency Depatments (EDs), to plan and pepae fo the challenges a futue pandemic may bing. 6 Hospitals face paticula challenges duing an influenza pandemic. ost impotant is ensuing that thee is sufficient, sustainable fontline wokfoce available in all essential aeas. Duing any disaste elief effot thee ae baies to staff paticipation including tanspot poblems, esponsibilities of staff Abstact Objective: This study was designed to investigate acute hospital pandemic influenza pepaedness in Victoia, Austalia, paticulaly focussing on planning and management effots. ethods: A pospective study was conducted by questionnaie and semi-stuctued inteview of health manages acoss the Victoian hospital system fom July to Octobe Paticipants with esponsibility fo emegency management, planning and opeations wee selected fom evey hospital in Victoia with an emegency depatment to complete a questionnaie (esponse ate 22/43 = 51%). Each espondent was invited to paticipate in a phone-based semi-stuctued inteview (esponse ate 11/22 = 50%). esults: ual/egional hospitals demonstated highe levels of clinical (86%) and non-clinical (86%) staff contingency planning than metopolitan hospitals (60% and 40% espectively). Pandemic plans wee not being sufficiently tested in execises o dills, which is likely to undemine thei effectiveness. All espondents epoted hand hygiene and standad pecautions pogams in place, although only one-thid (33%) of metopolitan espondents and no ual/egional espondents epoted being able to meet patient needs with high levels of staff absenteeism. Almost half Victoia's healthcae wokes wee unvaccinated against influenza. Conclusions and implications: Hospitals acoss Victoia demonstated diffeent levels of influenza pandemic pepaedness and planning. If a moe sevee influenza pandemic than that of 2009 aose, Victoian hospitals would stuggle with wokfoce and infastuctue poblems, paticulaly in ual/egional aeas. Staff absenteeism theatens to undemine hospital pandemic esponses. Vaious stategies, including education and communication, should be included with in-sevice taining to povide staff with confidence in thei ability to wok safely duing a futue pandemic. Key wods: pandemic, hospitals, influenza, Austalia, planning as caes, lack of staff knowledge of isks o thei ole in the esponse, and staff safety feas fo family o themselves though thei paticipation. 7 The type of disaste also mattes, with wokes epotedly less likely to tun up fo wok duing an influenza pandemic than duing a weathe elated disaste. 7 Studies have shown that up to half the healthcae wokes may not espond if equied to wok duing a sevee influenza pandemic. 8,9 The willingness of any paticula staff membe to espond was stongly linked to the type of woke ole and the peceived impotance of that ole. 9,10 Duing the 2009 H1N1 pandemic, Austalian health woke absenteeism was as high as it was in 2007, when Austalia expeienced its wost influenza season in ecent yeas School of Public Health and Human Biosciences, La Tobe Univesity, Victoia 2. WHO Collaboating Cente fo efeence and eseach on influenza, Victoia Coespondence to: Ben Dewa, School of Public Health and Human Biosciences, La Tobe Univesity, Fanklins Steet (City) Campus, 215 Fanklin Steet, elboune, Victoia 3000; bj.dewa@gmail.com Submitted: June 2013; evision equested: August 2013; Accepted: Octobe 2013 The authos have stated they have no conflict of inteest. Aust NZ J Public Health. 2014; 38:184-90; doi: / Austalian and New Zealand Jounal of Public Health 2014 vol. 38 no. 2

2 Health Sevices Hospital pepaedness fo pandemic influenza in Victoia Stategies exist that may impove woke paticipation such as staff vaccinations, povision of antivial theapies and effective education and communication pogams. 12 Impotantly, a study of infection ates afte the peak of the 2009 H1N1 pandemic showed that healthcae wokes had simila levels of infection to the geneal community, and that household athe than wokplace exposue was moe stongly associated with infection. 13 The povision and coect use of pesonal potective equipment (PPE) such as gloves, gowns, masks and face shields may be an effective measue to educe tansmission. 13 Howeve, once a pandemic occus, egula stocks of PPE will be apidly depleted and it will be the esponsibility of each hospital to calculate its equiements and stockpile equied amounts of PPE. 14 Hence, this is a potential weakness in the cuent pandemic plans fo healthcae wokes. Epidemic outbeaks of influenza in healthcae facilities have been associated with low staff vaccination ates. 15 Staff vaccinations ae theefoe essential to pevent o amelioate vius outbeaks amongst patients and staff in hospitals. 15 Inceasing healthcae wokes vaccination ates leads to educed influenza amongst patients and staff, educed motality among patients, a safe wokplace and a moe poductive wokplace though educed sick leave. 15 Ethical aguments can be made that the welfae of patients and co-wokes outweighs the pesonal pefeences of staff, and that staff vaccinations should be made mandatoy. 15 Hospitals play an integal ole in the public health esponse to pandemics; 16 howeve, few eviews have been published of Austalian hospitals pefomance duing the 2009 H1N1 pandemic o how planning has since been modified. This study was designed to investigate pandemic influenza pepaedness in acute cae hospitals in Victoia, Austalia, with a focus on policy, planning and management effots, and the subsequent changes made to counte futue influenza pandemics. ethods The Austalian Institute of Health and Welfae s y Hospitals website 17 was used to identify all Victoian hospitals with an ED. All 43 hospitals identified wee contacted by phone to identify the Emegency anagement Coodinato o simila peson in chage of emegency management, planning and opeations. A questionnaie was pepaed based on the hospital equiements descibed in the Victoian Health anagement Plan fo Pandemic influenza 16 and a 2010 epot by Spung et al. 18 The questionnaie coveed thee main aeas: hospital planning infomation; wokfoce issues; and infastuctue and suge capacity. The questionnaie was piloted with a small goup of colleagues. Staffing levels suggested by Spung et al. wee used to identify and test potential capacity. Questionnaies wee mailed to espondents, who wee asked to complete it with colleagues if necessay. One esponse fom each hospital was equested. eminde phone calls wee placed two weeks afte posting. Afte completing the questionnaie all paticipants wee invited to take pat in a follow-up qualitative semistuctued telephone inteview coveing pesonal and pofessional expeiences duing the pandemic. Data on healthcae woke immunisation was povided by the Victoian Infection Contol Nosocomial Infection Suveillance System (known as VICNISS) with pemission fom the Victoian Depatment of Health. All identifying details wee emoved pio to analysis. This wok was appoved by the La Tobe Univesity Faculty Human Ethics Committee (efeence: FHEC11/095). Desciptive statistics with a 95% confidence inteval wee calculated fo univaiate and bivaiate analysis. Text esponses wee analysed using a qualitative appoach and gouped into themes. esults Staff fom 22 hospitals povided esponses to the questionnaie, a esponse ate of 51%. Seven esponses wee eceived fom ual/ egional hospitals (7/16 = 44%) and 15 fom metopolitan hospitals (15/27 = 56%) with the latte including one pivate hospital. Hospital sizes anged fom 35 to 885 hospital inpatient beds (median = 260, metopolitan median = 352, ual/egional median = 101) with 184 to 5,000 full-time equivalent staff (median = 2,370, metopolitan median = 2,485, ual/ egional median = 944) and between 8 and 62 ED and ICU beds combined (median = 44, metopolitan median = 52, ual/egional median = 17). All but two ual sevices (91%) epoted confimed cases of H1N1 influenza at thei hospital duing the 2009 H1N1 pandemic. Nine paticipants (41%) indicated that they wee the Emegency anagement Coodinato o simila title, five espondents (23%) held positions elated to infection contol, fou (18%) wee ED anages and thee espondents (14%) identified thei ole as elating to Nusing o Acute Sevices. Half of the questionnaie espondes consented to an inteview. All espondents suveyed indicated that an incident contol system (ICS) was in place and all but thee had been intenally eviewed within the last two yeas (86%). The most fequently cited famewoks o pactices (multiple could be cited) upon which systems o plans wee developed wee: Hospital esilience Code Bown Policy Famewok (11 citations: 50%); Victoian Health anagement Plan fo Pandemic influenza (5 citations: 23%); and the Austalian Health anagement Plan fo Pandemic influenza (4 citations: 18%). Othes included the National Austalian Standad 4083/1997; WHO Stategic Plan 2007; NSW Health influenza Pandemic Plan 2006; and the New Zealand influenza Pandemic Action Plan 2006 (1 citation each: 5%). Of these, 16 plans (73%) wee endosed at the executive level, fou (18%) wee endosed by the CEO and one (5%) was not yet endosed (and one did not povide a esponse). Staff cited by espondents as commonly involved in planning woked in infection contol, occupational health and safety depatments, o wee medical staff o hospital executives. Othe depatments (fo example supply, engineeing, ICUs and phamacy) wee pooly epesented (Table 1). etopolitan espondents epoted highe ates (60%) fo testing of plans in a functional execise o dill than ual/egional espondents, whee no testing was epoted (Table 2). In the event of anothe pandemic, espondents indicated that cuent planning effots would be effective only to a point, with impotant vaiables being the seveity of the next vius and wokfoce availability. None of the ual/egional espondents and almost half the hospitals oveall (45%) epoted that patient needs could not be met with ates of staff absenteeism expected duing a pandemic (Table 2). The esults of the suvey indicated that compliance with standad pecautions taining and the pesence of hand hygiene pogams was 2014 vol. 38 no. 2 Austalian and New Zealand Jounal of Public Health 185

3 Dewa, Ba and obinson Aticle high. Howeve, in the yea following the 2009 pandemic, aggegate Victoian healthcae woke influenza vaccination ates again fell to below 50% (Figue 1) with medical staff (39.6%) and nusing staff (44.3%) demonstating the lowest ates. Table 1: Fequency of involvement of cetain hospital goups in the development of hospital emegency and pandemic plans. Goup Fequency Count Infection Contol 90% 19 Occupational Health & Safety 43% 9 edical/clinical Diecto o 38% 8 edical Staff Hospital Executive 33% 7 Emegency anagement 33% 7 Committee Diecto of Nusing/ Nusing Staff 24% 5 Emegency Depatment 24% 5 Quality and isk 14% 3 Supply 10% 2 Engineeing 10% 2 Depatment of Human Sevices/ 10% 2 Health icobiology 10% 2 Chief Opeating Office 5% 1 edical Administation 5% 1 ICU 5% 1 Bed Coodinatos 5% 1 Phamacy 5% 1 Sevice anages 5% 1 Allied Health 5% 1 Envionmental Sevices 5% 1 Theate 5% 1 Secuity 5% 1 Figue 1: Healthcae woke influenza vaccination ates fo Victoia. 70% % 50% 40% 30% 20% 10% 0% edical Nusing Allied Health Souce: VICNISS. Note: Emegency staff data was not collected in Non- Clinical Although anxiety was obseved by inteviewees to be high among staff duing the 2009 pandemic thee was no obseved efusal to wok. Inteviewees descibed a vaiety of stategies employed by hospitals to educe infection exposue and staff anxiety, including: ceating fontline flu teams that dealt exclusively with influenza patients theeby educing contact fo othe staff, identifying and emoving susceptible healthcae wokes such as pegnant staff fom exposue, and establishing mandatoy daily update meetings fo depatment heads that wee also available to othe staff. Education both befoe and duing the pandemic to keep staff awae of potocol updates was seen as a key challenge that was necessay to educe uncetainty. The espondents peceived capacity of hospitals to meet pandemic infastuctue and supply demands was mixed. Even at hospitals with few pandemic-elated pesentations, infastuctue capacity was identified as a potential weakness if patient numbes had significantly inceased. Emegency depatments poved the geatest management challenge. Common poblems identified by inteviewees ae shown in Box 1. Inteviewees commented that due to the natue of patient pesentations duing the 2009 pandemic, plans based on the assumption that infectious disease wads would be equied to manage lage numbes of admissions wee found to be edundant. Whee possible these plans wee adapted by moving depatments close to the ED elsewhee and expanding the ED into the newly ceated space. Laboatoy Emegency Othe Aggegate Box 1: Poblems identified in emegency depatments. Little o no scope to expand capacity Single enty points so that enty of patients with influenzalike illness (ILI) could not be sepaated fom those without ILI No waiting oom segegation fo ILI patients Inability to clean cubicles effectively o in a timely way between patients ual/egional espondents moe commonly epoted maintaining stockpiles of medical equipment, pesonal potective equipment, medication and basic supplies adequate to manage a mass casualty event than metopolitan espondents. Despite this, ual/ egional espondents aely epoted access to exta ventilatos when needed o capacity to expand patient isolation within ICUs (Table 2). ual/egional hospital espondents also expessed concen that supply was not available duing the pandemic eithe fom pivate o govenment supplies, paticulaly fo P2/N95 masks. etopolitan espondents epoted fewe supply issues. Although mask supplies had to be monitoed, stocks wee available fom both govenment stockpiles and usual supplies. etopolitan hospitals placed geate eliance on the elease of govenment stocks due to financial challenges and a lack of stoage capacity limiting the ability to stockpile. The supply of essential equipment and consumables duing a pandemic was aised as a concen fo the health system as a whole, paticulaly given the secto s move towads just-in-time supply chains. The lack of timely patient test esults fom influenza polymease chain eaction (PC) testing was also identified as an issue by some espondents. Pandemic communication pocesses wee felt by one inteviewee to be enhanced by ensuing thee was a single co-odinato to eceive, co-odinate and distibute intenal and extenal infomation. The majoity of ual/egional hospital manages inteviewed felt that communication and the level of pandemic esponse by the Victoian Depatment of Human Sevices (DHS), now the Victoian Depatment of Health, was diffeent fo ual/egional aeas than fo metopolitan aeas, with esponses to egional queies o equests fo help peceived as slow and possibly hampeed by indiect communication though egional hubs athe than diect communication with a cental body. The content of communication was also a souce of concen, as case definitions and diagnostic 186 Austalian and New Zealand Jounal of Public Health 2014 vol. 38 no. 2

4 Health Sevices Hospital pepaedness fo pandemic influenza in Victoia Table 2: Details of questionnaie esults including analysis of diffeences between metopolitan and ual/egional hospital esponses. 95% Confidence Intevals fo Diffeences: ual - etopolitan etopolitan ual/egional ean Diffeence Lowe Uppe Hospital Planning Y N DK A Y N DK A (P - P) 95%CL 95%CL Is thee a pocess of incident management (such as an incident action plan) in place? % 0.0% 0.0% Have incident management positions been detemined with clealy defined oles and leadeship? % 0.0% 0.0% Ae clinical staffing levels accounted fo in the plan? % 1.1% 50.4% Ae non-clinical staffing levels accounted fo in the plan? % 21.1% 70.4% Ae equipment contingencies accounted fo in the plan? % -23.4% 21.4% Ae space contingencies accounted fo in the plan? % -29.0% 13.7% Have incident escalation tigge points fo impact on hospital opeations been set in the event of a pandemic? % -55.4% 7.8% Have plans been tested in a functional execise o dill? % -74.3% -45.7% Wokfoce Ae staff willing to take antivial pophylaxis medication? % -53.6% 7.9% Ae all staff tained in standad infection contol pecautions? % 0.0% 0.0% Does the hospital have a hand hygiene pogam? % 0.0% 0.0% Ae staffing pattens designed to change at diffeent opeating stages? % -41.1% 22.0% Can the hospital meet patient needs at the stages identified above with 25-40% of staff absent? % -47.1% -19.6% Infastuctue and Suge Capacity Ae coodination systems and ageements in place with neighbouing health povides? % -47.4% 15.0% Is thee capacity to expand the ICU to 300% of cuent capacity? * % -5.8% 34.4% In a mass casualty event (CE) does you hospital have stockpiles of equipment? % 7.6% 57.2% In a mass casualty event (CE) does you hospital have stockpiles of PPE? % 19.6% 47.1% In a mass casualty event (CE) does you hospital have stockpiles of medication? % -5.0% 54.5% In a mass casualty event (CE) does you hospital have stockpiles of basic supplies? % -5.3% 43.4% Does the hospital have one ventilato pe citical cae bed? % -73.9% -13.7% Ae contingency plans in place to obtained moe ventilatos up to planned limits within 6-12 hous? % -21.4% 42.4% Does the hospital have the capacity to expand isolation of patients in the ICU including povision of negative aiflow? % -70.4% -21.1% Have aeas that can be sepaately ventilated been identified? % -30.9% 27.1% Is the hospital able to accommodate a lage numbe of deceased in a espectful way? % -28.1% 35.7% Y = Yes. N = No, DK = Don t Know, A = Abstain, P = Yes Popotion etopolitan, P = Yes Popotion ual/egional, CL = Confidence Limit * Hospitals without an ICU wee maked as A (Abstain) Confidence Intevals wee calculated fo the diffeence between two popotions allowing fo the finite population size: Whee nx is the numbe of hospitals, eg. n is the numbe of metopolitan hospitals with emegency depatments in Victoia x is the numbe of espondents, eg. is the numbe of ual/egional espondents Note: Whee values wee missing the hospital was emoved fom that section of the analysis. CL P P 1.96 n P 1 P n P 1 P n 1 n vol. 38 no. 2 Austalian and New Zealand Jounal of Public Health 187

5 Dewa, Ba and obinson Aticle citeia changed. Testing, tacing, teatment and epoting equiements fom DHS wee cited by inteviewees as majo issues fo hospitals. Although these citeia wee late eased, the initial potocols wee seen by some inteviewees as too stict and impactical to achieve, especially had the numbe of pesentations apidly inceased. Inteviewees also commented that the autonomy and devolved govenance aangements of Victoian hospitals wee challenged by DHS instuctions to maintain nomal opeations duing the pandemic, despite thei hospital emegency plans calling fo a scaling down of egula sevices at cetain tigge points. It was suggested that the combination of apidly changing and potentially impactical instuctions may have contibuted to a desie by some hospitals to act moe independently in thei management of the pandemic. espondents defined a numbe of changes that occued as a esult of the pandemic. A summay of these is pesented in Table 3. ost espondents epoted needing to develop o adapt thei esponse to meet changing testing and teatment potocols acoss the vaious stages of the pandemic. Those inteviewed believed that hospitals managed the pandemic well, eithe though effective planning, a lack of pesentations, o a combination of both (all esponses scoed 7+ on a scale of 1 to 10). Limitations The main limitations of this study ae the small numbe of hospitals in Victoia with an ED, and a elatively low esponse ate. In addition, the planning famewoks identified by espondents only epesent the knowledge of the espondents athe than the pactice that might be implemented, the famewok that was used to wite the hospital plan, o any co-odinated action that govenments might take should a pandemic aise. While complete data on Victoian hospital bed-numbes was not available, suvey espondents did epesent a boad cosssection of the Victoian hospital system, including small, medium and lage hospitals fom both metopolitan and ual aeas. The study was also stengthened by the addition of qualitative inteview data to expand on the quantitative suvey esults. Discussion Pandemics can be vaiable in thei disease seveity anging fom vey mild, as occued in 2009, to vey sevee, as happened in the Table 3: Changes in hospital pactice identified following eview of the 2009 pandemic. Change aea Summay of suggested evisions evision of the existing plans Addition of a step-by-step potocol to the existing pandemic plan with pactical steps in pandemic management and when they should be done, contact numbes, etc Development of plans to set up flu houses and clinics fo tiage, funding pemitting Incopoation/inclusion of the local community in moe effective management of the pandemic oe poactive management of the elationship with State Govenment Geate involvement consultation and coodination with the local division of geneal pactice now called a edicae Local. Development of a new business continuity plan Expanded capacity Use of in-house validated PC diagnostic kits fo seasonal influenza testing Definition of aeas within the hospital whee patients can be decanted fo cohots of pandemic influenza patients, such as outpatient aeas fo patients who need assessment befoe going home, and patients who ae not vey sick but need isolating and hospital management Expansion of capacity to isolate patients in futue hospital designs Allocation of stoage aeas fo pesonal potective equipment such as tissues, gloves, handwash, etc, in stategic pats of the hospital Impoved communication Embedding of daily meetings as pat of opeations in a pandemic Establishment of a single cental coodinato as pat of the hospital incident management team to coodinate intenal and extenal communication and 'close the infomation loop' Fomalised documentation that can be eleased in a timely way duing the next pandemic that defines the ole of staff (paticulaly ED staff) at vaious pandemic stages Incopoation into plans of factsheets developed by the State Govenment fo poviding infomation to the community 'Spanish influenza' of when an estimated 50 million people died globally. 16,19 odeate pandemics wee seen with the moe ecent Asian flu in 1957 (H2N2) and the Hong Kong flu in 1968 (H3N2) 1 in which thee wee an estimated two million and one million deaths woldwide, espectively. When the pandemic aived in ay 2009, Victoian hospitals wee in vaying stages of pepaation and many found thei plans to be inadequate to the challenges at hand. The lack of citations fo the state o national famewoks as the basis fo hospital pandemic plans was supising, and although the easons fo this wee not exploed, the lack of a consistent famewok on which hospital pandemic plans wee based may hampe state and national co-odination effots in the futue. The Victoian hospitals Code Bown emegency esponse famewok was the most commonly cited basis fo hospital pandemic plans. This famewok was designed fo extenal situations likely to challenge a hospital s capacity to maintain nomal sevices; 20 howeve, Code Bown esponses ae typically designed and tested fo fast-onset, mass casualty incidents (e.g. a tain collision) with potentially vey diffeent challenges to the demands of a pandemic, which has a elatively slow patient influx that can apidly escalate. 21 Duing the 2009 pandemic, hospital plans that wee paticulaly designed to espond to an influx of inpatients wee found to be inadequate to meet the pessues placed on outpatient sevices, EDs, ICUs and high dependency units. Without a pogessive, scalable, adaptable and specific esponse to the demands of the pandemic at hand, hospitals isk not being able to adapt and cope in a timely way. Othe studies have also called fo the elationship between pandemic and disaste planning to be claified in the wake of the 2009 pandemic. 22 Hospitals may benefit fom developing specific pandemic plans in addition to thei moe geneic Code Bown esponse. The Code Bown Famewok 20 descibes the ole of Emegency anagement Coodinato as the peson who is in oveall chage of emegency management, planning and opeations. As no suggested title is povided by the state o national famewoks fo this hospital ole in a pandemic, it was assumed the ole of co-odinating the oganisation s pandemic esponse would also est with the holde of the ole established by the Code Bown Famewok. Despite the 188 Austalian and New Zealand Jounal of Public Health 2014 vol. 38 no. 2

6 Health Sevices Hospital pepaedness fo pandemic influenza in Victoia Code Bown famewok being the most commonly cited basis fo plan development, only thee espondents had adopted the suggested title, which made it difficult fo the authos of this pesent study to identify the peson(s) caying out this ole in the hospital. In addition to the lack of consistency in ole titles that hospitals have adopted, the divesity of knowledge and expeience of those who esponded in this study identifying themselves as esponsible fo the hospital s pandemic esponse may potentially futhe hampe co-odination effots in an emegency. The challenges expeienced by some Victoian hospitals in the 2009 pandemic wee exacebated by the geogaphic concentation of cases, with the vast majoity of confimed cases being epoted fom metopolitan elboune with paticula foci in the oute nothen and westen sububs. 23 The impotance of using suveillance systems to undestand geogaphical distibution and thei eview duing pandemics fo public health puposes has been noted befoe. 24 Inteestingly, despite the need fo inta-oganisational and possible inte-oganisational commitment to extenal emegency esponses, none of the espondents to this study indicated that pandemic plans had been endosed at the boad level. A common theme emeging fom inteviews was the lack of knowledge, planning o belief in wokfoce capacity. These concens appea justified based on pevious studies and evidence. 8,9,11 eviews by othes 25 of expected absenteeism based on hypothetical scenaios, have shown absenteeism vaying fom 13% to 85%.The Victoian Health anagement Plan fo Pandemic influenza 3 suggests staff absenteeism levels of 30 50% might be expected duing a pandemic. Self-epoted absenteeism by emegency medical and nusing staff duing the 2009 pandemic was as high as 56.6%. 25 The pessues of the pandemic wee also epoted to have negatively affected the cae fo non-influenza patients in the ED. 22 Ou data suggest that even with an anticipated 25 40% of staff absent, less than a quate of Victoian hospitals (23%) expected to meet thei patients needs, with none of these being in ual/egional aeas. Staff absenteeism in an influenza pandemic is diven by both pesonal sickness and the staff membe s uncetainty about thei ability to wok safely fo fea of infecting family and fiends. 7 Although the latte has been shown to be elatively unimpotant as a motivato fo absenteeism, 22 ates of obseved absenteeism pehaps ought to be highe; it has been shown, fo example, that clinicians in paticula will continue to attend wok despite having influenza-like illness, in beach of clinical guidelines. 25 Education is impotant fo educing absenteeism as fontline staff may not fully appeciate the effectiveness of basic peventative measues 10 and inteviewees in this study affimed that othe stategies such as vaccination, the povision of influenza antivials, education and stuctued staff communication can be effective, as has also been noted elsewhee. 10 The ole vaccination might have played in educing absenteeism duing the 2009 pandemic was undemined by issues of timing and lack of uptake. A specific vaccine against the pandemic vius was not available until afte the fist wave of the pandemic had passed, and when it did become available in Octobe 2009 uptake was low, with only an estimated 18.1% of the Austalian population vaccinated. 26 While the level of potection affoded by the seasonal tivalent vaccine was uncetain at the time 27,28 it was late shown to be geneally beneficial. 29 The National Health and edical eseach Council has ecommended that all staff involved in patient contact be vaccinated against influenza. 30 While ates of vaccination have impoved ove the past six yeas and peaked in 2009, ates among Victoian medical and nusing staff emain low (Figue 1). To impove staff vaccination ates it has been suggested that influenza vaccination should be made mandatoy. 31 Despite being citical to effective hospital functioning, non-clinical staff tend to view thei oles as less essential than clinical staff and have been shown to be less willing to attend duing a pandemic than thei clinical colleagues. 9 etopolitan hospital plans failed to adequately conside staffing contingencies, paticulaly fo non-clinical staff. ual/egional hospitals displayed geate diligence in staff planning, which likely eflected wokfoce shotages and the lack of access to nusing banks and agency staff that ae enjoyed by metopolitan hospitals. Once a pandemic occus, egula stocks of pesonal potective equipment (PPE) will be apidly depleted and, in pinciple, each hospital should take esponsibility fo stockpile levels. 14 The pe-exposue use of antivial dugs 32 could easonably be a pat of the PPE amouy, as modelling shows that pophylactic use does not impede the ability to contain influenza outbeaks when used post-exposue. 32 Aided by thei elative geogaphic poximity, metopolitan hospitals demonstated geate capacity to co-odinate effots among themselves, including supply. In contast, ual/egional espondents identified stock depletion and communication with govenment on this issue to be poblematic in the 2009 pandemic. As has been noted peviously, 11 delays in eceiving PC influenza test esults made the management of suspected influenza cases difficult, delayed clinical decision-making, and impaied the ability to cohot patients effectively. To educe esult tunaound time, some hospitals puchased and validated influenza PC kits and developed in-house influenza testing capacity. This was seen as an effective means of impoving infomation flow and building oganisational capacity that could be adopted moe boadly. The whole-of-govenment simulated influenza pandemic execise Execise Cumpston in 2006 was designed to assess the esponse capacity of the health system; howeve, only one hospital in Austalia the oyal Bisbane and Women s Hospital in Queensland was involved and the dill did not addess hospital suge equiements. 33 The Victoian Hospital esilience Code Bown Famewok 20 ecommends that execises be conducted annually. Ou esults suggest that the effectiveness of planning effots has been undemined in Victoia by a lack of egula testing using execises and dills. Testing influenza pandemic pepaedness is an integal pat of effective planning, the value of which cannot be undeestimated in evaluating the stengths and weaknesses of cuent plans. 34,35 In addition, the need fo adaptable plans to ensue equity in the distibution of esouces has been noted 36 with a need fo national and, by extension, local plans to be appopiately flexible fo maximum public health effectiveness. Conclusions Hospitals acoss Victoia displayed diffeent levels of pepaedness fo an influenza pandemic. Dedicated hospital pandemic plans need to be developed that ae adaptable to the conditions of the pandemic at hand; howeve, the effectiveness of plans 2014 vol. 38 no. 2 Austalian and New Zealand Jounal of Public Health 189

7 Dewa, Ba and obinson Aticle is possibly being undemined by a lack of testing and a lack of famewok consistency acoss the state. Hospital manages and policy makes should put pocesses in place to ensue plans ae audited and tested on an annual basis. A numbe of stategies contibute to hospital pepaedness, including education and communication plans fo educing staff absenteeism. Staff contingency planning is a citical aea in which elboune metopolitan hospitals could impove. The need fo the State Govenment to povide stong leadeship, clea pactical advice and a means of developing effective capacity was identified. Supply issues wee aised as an example of how competing financial and poductivity pessues wee educing hospital management s capacity to plan fo pandemics effectively. Even at its peak, the H1N1 pandemic in 2009 did not ovewhelm citical cae capacity o hospital opeations in eithe the metopolitan o ual/egional aeas of Victoia, possibly because of its geogaphical heteogeneity. If a moe sevee influenza vius was to become pandemic, such as the A(H7N9) vius that has caused ecent human infections and deaths in China, 37 it would put much geate pessue on the Victoian health system and hospitals, who would stuggle with wokfoce and infastuctue issues, paticulaly in ual/ egional aeas. Hospital and management pepaedness is still an issue and this pape would be a useful eminde fo hospital manages and policy developes, at a state and national level thoughout Austalia and New Zealand, to eview and impove thei futue effots in managing influenza pandemics. Acknowledgements The elboune WHO Collaboating Cente fo efeence and eseach on influenza is suppoted by the Austalian Govenment Depatment of Health and Ageing. Thank you to Ann Bull fom VICNISS fo supplying data on hospital staff influenza vaccine ecods. The VICNISS Coodinating cente is funded by the Victoian Depatment of Health. 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