H1N1: Pediatric Surge Capacity Strategies and Lessons Learned

Transcription

1 H1N1: Pediatric Surge Capacity Strategies and Lessons Learned Daniel B. Fagbuyi, MD, FAAP MAJ, MC, USAR Medical Director, Disaster Preparedness and Emergency Management Children s s National Medical Center, Washington, DC Assistant Professor, Pediatrics and Emergency Medicine The George Washington University School of Medicine, Washington, DC Member, Disaster Preparedness Advisory Council (DPAC), American Academy of Pediatrics 4 th National Emergency Management Summit March 3 5, 2010

2 Objectives H1N1 outbreak (national impact) Discuss the pediatric impact in the Nation s s Capital from frontlines at Children s s National Highlight strategies adopted by Emergency Departments, Hospitals, and Outpatient facilities to augment pediatric

3 Objectives Enumerate what we learned from the 1 st and 2 nd wave of the pandemic Provide possible solutions to address noted gaps

4 Objectives What can state administrators, emergency managers, healthcare workers, first responders and others do? Discuss the next steps/future directions

5 Pandemic (H1N1) 2009 Influenza Virus

6 2009 H1N1 Outbreak Occurred very late in the season Remarkable heterogeneity across US Affected young people disproportionately Caused widespread illness; some severe or fatal Socially disruptive, especially for schools Tens of thousands of health workers and others responded worldwide

7 H1N1 Impact on Children s s National Emergency Department Patient Volume Non-ILI ILI Patient Volume 10/12/ /13/ /14/ /15/ /16/ /17/ /18/ /19/ /20/ /21/ /22/ /23/ /24/ /25/ /26/ /27/ /28/ /29/ /30/ /31/ /1/ /2/ /3/ /4/ /5/ /6/ /7/ /8/ /9/ /10/2009 Daily Influenza-like illness (ILI) and Emergency Department (ED) volume Fall 09 H1N1. Solid line represents ED baseline volume. Date

8 Surge Surge capacity: the ability of a health system to rapidly expand beyond normal services to meet the medical demands during a public health emergency. Key to success is early identification of the indicators/tipping points/triggers!

9 Quick Registration. Surge Strategies DOB and Name; Copy insurance card Cohort Patients. ILI pts together and physically separated from non-ili pts. RPMS Rapid Rapid Pre-printed Medical Screen. Pre-printed antiviral scripts. Alternate Care Sites Rapid Screening Unit (RSU). Tents, Parking lots, Drive-throughs, Orthopedics clinic, other non-clinical areas.

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12 Surge Strategies Augment Staffing Offer moonlighting; financial incentives Credential senior fellows as attendings Utilize backup providers/residents Convert Researchers to full clinical FTE Pull staff from away rotations Reach out to local DOH, ESARVHP, MRC, NDMS, etc

13 Surge Strategies Limit testing/ancillary Services Proactive/Aggressive communication Work with internal PR Outreach to communities and community providers (ideally before a disaster) Outreach to mainstream and local media (tv and radio; build on previous relationships) Facebook; Twitter Phone hold messages Organization s s website-- -- Flu center and links

14 Surge Strategies Develop treatment algorithms for inpatient and outpatient Different from initial CDC recommendation; high risk <2yrs. H1N1 test on only patients to be admitted. Reverse Triage Memorandum of Understanding (MOUs) Re-defining the pediatric patient Cancel elective procedures Last on the list; cash cow for many hospitals Increase # of Direct Admissions Telemedicine

15 H1N1 Influenza Testing and Treatment Algorithm for Clinicians 9/14/2009 Febrile Respiratory Illness Fever > 100 degrees (37.8C) AND Respiratory symptoms (Cough Sore Throat Rhinorrhea Nasal Congestion) YES Infection Control Place surgical mask on patient and family and maintain masked status in waiting areas Designate separate waiting areas when possible Standard, Contact and Droplet Precautions for staff providing patient care 1 Private room with closed door if possible OR curtainedroom with mask remaining on patient and family Does Patient Require Hospitalization? YES Hospitalized Patient Maintain Standard, Contact and Droplet Precautions 1 Obtain NP Aspirate and send for Repiratory Viral PCR Begin empiric antiviral therapy (even if >48 hrs symptoms): Oseltamivir (Tamiflu) OR Zanamivir (Relenza) When Seasonal Flu co-circulating, use Zanamivir alone or combination Oseltamivir + Rimantidine OR Amantidine See separate dosing guidelines for antiviral treatment Clinical judgment for possible additional antibacterial therapy 1 Negative pressure room, fit-tested N-95 mask required for aerosol generating procedures: e.g. Bronchoscopy, open airway suctioning, cardiopulmonary resuscitation, intubation. N-95 NOT required for: NP swab or aspirate collection, in-line (closed) airway suctioning, nebulized medication administration NO NO No influenza testing recommended. Additional evaluation/followup as clinically indicated. Non-Hospitalized Patient Testing for influenza/h1n1 NOT recommended Consider additional evaluation for other respiratory conditions and co-infections, If warranted Symptoms <48 hours: TREAT HIGH RISK 2 Antiviral Treatment? Symptoms >48 hours: CONSIDER NOT HIGH RISK NO TREATMENT 3 2 Persons at HIGH RISK of complications: ( < 2 yrs ; >65 years of age; <19 yrs of age on long term aspirin therapy (Reye syndrome); pregnant women; chronic underlying pulmonary (including asthma), cardiovascular, hepatic, hematologic, neurologic, neuromuscular, or metabolic disorders; residents of chronic care facilities; immunosuppression (meds or HIV) 3 Healthy persons with suspected H1N1Inlfuenza presenting with uncomplicated febrile respiratory illness typically do not require treatment..

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17 Lessons Learned Closing schools did not stop the spread of H1N1 and had significant downsides Confusion over who had the authority to close/open schools Cohorting patients in EDs was helpful in rapid assessment/triaging and infection control

18 Lessons Learned Stockpiling antivirals and pandemic planning was prudent Pre-printed antiviral prescriptions were helpful and saved time Pre-scripted medical screening questions were useful

19 Lessons Learned CDC reports lagged front-line situational awareness Daily conference calls with local DOH and healthcare coalitions were very useful Public health system was limited in its ability to execute its mission

20 Lessons Learned Stockpiled antivirals did not reach the community pharmacies in timely manner WHO pandemic alert caused confusion as it did not reflect severity Communication with the media, public, and health care workers was difficult; messages kept changing The dynamic was one of change and adaptability

21 Outstanding Challenges Complex message on vaccination Seasonal and H1N1 vaccines Different recommendations for different ages LAIV versus injected Distrust of vaccines Historical references and Media disinformation Vaccine payment issues Low Pediatric vs. Adult provider reimbursement

22 Pragmatic Solutions: Surge States need Federal guidance on altered standards of care All EDs (adult and pediatric) need to be prepared to care for children Community organizations, schools, childcare facilities should be able to care for and plan for emergencies involving children, especially those with chronic diseases and special needs

23 Pragmatic Solutions: Communications Public health, hospitals and private health partners need to collaborate and communicate with one another Coordination across all levels of government along with stakeholder input should be the standard Pediatric experts should be included on public health frameworks and communications

24 Pragmatic Solutions: Education Pediatric-focused educational messages should target caregivers and communities 1 st responders and healthcare providers should be educated on unique vulnerabilities of children and the transportation issues that may arise; family-centered care for special needs children Mass media is a unique tool, but message has to be consistent. Who is the messenger?

25 Pragmatic Solutions: General Build community resilience by being involved in the community can can you relate? Offer psychological first aid and beyond for children Scarce resources how do we prioritize them; what are the ethical considerations?

26 Next Steps Improve real time surveillance Statewide beds availability Situational awareness Rapid deployment of countermeasures and framework operations Consult and enlist pediatric partners at all levels of preparedness and response!

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28 H1N1: Pediatric Surge Capacity Strategies and Lessons Learned Daniel B. Fagbuyi, MD, FAAP MAJ, MC, USAR Medical Director, Disaster Preparedness and Emergency Management Children s s National Medical Center, Washington, DC Assistant Professor, Pediatrics and Emergency Medicine The George Washington University School of Medicine, Washington, DC Member, Disaster Preparedness Advisory Council (DPAC), American Academy of Pediatrics 4 th National Emergency Management Summit March 3 5, 2010